NCSBN NCLEX (QUESTIONS WITH 100% CORRECT SOLUTIONS 2024 UPDATED GRADED A+), Exams of Nursing

Download NCSBN NCLEX (QUESTIONS WITH 100% CORRECT SOLUTIONS 2024 UPDATED GRADED A+) and more Exams Nursing in PDF only on Docsity! NCSBN NCLEX (QUESTIONS WITH 100 % CORRECT SOLUTIONS 2024 UPDATED GRADED A+) A LPN complains to the charge nurse that an unlicensed assistive person (UAP) consistently leaves the work area untidy and does not restock supplies. What is the best initial response by the charge nurse? 1Write down potential solutions to the problems today by shift's end 2Add this concern to the agenda of the next unit meeting 3Assure the staff nurse that the complaint will be investigated 4Explore for further identification about the nature of the problem - Solution 4 Explore for further identification about the nature of the problem The nurse assists with the reinforcement of information about breast self- examination to a group of college students. A female student asks when to perform the monthly exam. The appropriate reply by the nurse should include which statement? 1"Ovulation, or midcycle is the best time to detect changes." 2"Do the exam at the same time every month." 3"Right after the period, when your breasts are less tender." 4"The first of every month, because it will be easiest to remember." - Solution 3 The nurse is caring for a 75 year-old client with type 2 diabetes mellitus. The client should be instructed to contact the outpatient clinic immediately if which findings are present? 1An open wound on the heel with minimal discomfort 2Occasional hiccups and sneezing 3Sustained insomnia and daytime fatigue 4Persistent dryness and itching of the perineal area - Solution 1An open wound on the heel with minimal discomfort- A pregnant woman has been advised to alter her diet during pregnancy by increasing the intake of protein and vitamin C to meet the needs of the growing fetus. Which diet choice would best meet the woman's needs? 1. 1 cup of macaroni, three-fourths cup of peas, glass whole milk, medium pear 2. Scrambled egg, hash browned potatoes, one-half glass of buttermilk, large nectarine 3. 3 oz. chicken, one-half cup of corn, lettuce salad, small banana 4. Beef, one-half cup of lima beans, glass of skim milk, three-fourths cup of strawberries - Solution 4. Beef, one-half cup of lima beans, glass of skim milk, three-fourths cup of strawberries - A nurse is taking a health history from parents of a child admitted with possible Reye's syndrome. Which recent illness should the nurse recognize as being associated with an increased the risk for the development of Reye's syndrome? 1. Varicella 2. Meningitis 3. Hepatitis 4. Rubeola - Solution 1. Varicella - A Native American chief visits his newborn son and performs a traditional ceremony that involves feathers and chanting. The nurse comments to a colleague: "I wonder if he has any idea how ridiculous he looks - he's a grown man!" The nurse's comment is an example of what type of attitude? 1. Prejudice 2. Ethnocentrism 3. Discrimination 4. Stereotyping - Solution 1. Prejudice- A nursing student asks the licensed practical nurse (LPN) to explain the forces that drive health care reform. When responding to the student's question, what information should the nurse emphasize? 1. Increased competition between health care insurers 2. Increase in health care spending that's growing faster than the economy 3. Increase in the population who have health insurance 4. Increase in spending for end-of-life treatment - Solution 2 A child is admitted to the unit with the suspected diagnosis of pertussis (whooping cough). What is the priority nursing intervention for this child? 1. Maintain hydration and encourage fluids 2. Implement droplet precautions 3. Monitor respiratory rate and oxygen saturation 4. Anti- infective therapy - Solution 2 A client has an indwelling catheter with continuous bladder irrigation after undergoing a transurethral resection of the prostate (TURP) 12 hours ago. The LPN is unsure about an assignment by the charge nurse to hang an intravenous (IV) infusion that contains potassium. What resource should the LPN check first to determine if LPNs can administer IV medications? 1Employer policy and procedures manuals 2Nursing faculty from a local nursing program 3The nurse practice act of the state in which the practice takes place 4American Nurses Association (ANA) professional standards - Solution 3 The nurse is assisting with the delivery of a newborn infant. What is the priority nursing intervention for a normal newborn immediately after delivery? 1Dry off infant with a warm blanket or towel 2Apply identification bracelets 3Assign the one-minute APGAR score 4Obtain vital signs - Solution 1Dry off infant with a warm blanket or towel - The registered nurse is teaching a childbirth education class about postpartum depression. Which statement, made by a class member, indicates that more teaching is needed? 1"I will make an effort to talk with someone about my feelings if I start to feel overwhelmed." 2"It's common for women with postpartum depression to have delusions about the infant." 3"Women with postpartum depression have feelings of guilt and worthlessness." 4"I may experience postpartum depression up to a year after delivery." - Solution 2 The nurse is reinforcing information about the side effects of fluoxetine to a client. Which group of findings should be included? 1Diarrhea, dry mouth, weight loss, reduced libido 2Tachycardia, blurred vision, hypotension, anorexia 3Orthostatic hypotension, vertigo, reactions to tyramine, nausea 4Photosensitivity, seizures, edema, hyperglycemia - Solution 1Diarrhea, dry mouth, weight loss, reduced libido A client has a diagnosis of heart failure. Which intervention is most important for the nurse to implement prior to the administration of digoxin? 1Use the pulse reading from the electronic blood pressure device 2Take a radial pulse, counting for a full 60 seconds 3Check for a pulse deficit at least twice with another nurse 4Assess the apical pulse, counting for a full 60 seconds - Solution 4Assess the apical pulse, counting for a full 60 seconds - A client diagnosed with bipolar disorder refuses to take the prescribed medication. Which is the most therapeutic response by a nurse to the client's refusal of the medication? 1"You need to take your medicine. This is how you get better." 2"What is it about the medicine that you don't like?" 3"I can see that you are uncomfortable right now; let's talk about it tomorrow." 4"If you refuse your medicine, tell me how do you think you will get better?" - Solution 2 A parent expresses frustration and anger about the toddler constantly saying "no" and refusing to follow directions. The nurse should help the parent understand that this behavior meets which developmental need? 1Self-esteem 2Initiative 3Independence 4Trust - Solution 3 The LPN is assisting the RN to provide care for a client diagnosed with a traumatic brain injury. Using the Glasgow Coma Scale, when the client does not obey verbal commands to move, which technique will the RN use to evaluate motor function? 1Squeeze the trapezius muscle firmly 2Lift the client's arm and observe for pronation and drift 3Apply finger tip pressure for 10 seconds 4Rub the sternum with the knuckles - Solution 1Squeeze the trapezius muscle firmly - A newborn has hyperbilirubinemia and is being treated with a biliblanket. Which intervention is indicated during this therapy? 1Discontinue breastfeeding during treatment 2Rotate the neonate to treat all of his/her skin 3Restrict holding the newborn during treatment 4Provide more frequent feedings - Solution 4Provide more frequent feedings- A client with paranoid delusions stares at the nurse over a period of several days. The client suddenly walks up to the nurse and shouts, "You think you're so perfect, pure and good." How should the nurse respond? 1"You seem to be in a bad mood." 2"Perfect? I don't quite understand." 3"You sound angry right now." 4"That explains why you've been staring at me." - Solution 3 The client with coronary artery disease has a prescription for nitroglycerin transdermal patches. What is the best reason the client should not wear a patch for more than 12 to 14 hours each day? 1It can cause severe headaches 2It may no longer work as well 3It will cause profound hypotensive effects 4it will irritate the skin - Solution 2 A hospitalized infant is receiving gentamicin. Which nursing intervention should receive priority in the plan of care? 1Compare daily infant weights 2Monitor the infant's urine output 3Ensure appropriate fluid intake 4Maintain accurate intake and output - Solution 2 A newborn is diagnosed with hypothyroidism. In discussing the condition and treatment with the family, the nurse should emphasize which point? 1They can expect the child will be mentally retarded 2Administration of a thyroid hormone will prevent problems 3This rare condition is hereditary 4Physical growth and development will be delayed - Solution 2 A child is admitted to the hospital for emergency surgery. The child's parent reports several allergies. Which of these allergies should all the operative health care personnel be notified about? 1Perfumed soap 2Shellfish 3Balloons 4Mold - Solution 3 A practical nurse (PN) team member identifies that the fundus is boggy for a woman who is gravida 4 para 4 and is two hours after a spontaneous 3Discuss the diet with the client to learn the reasons for not following the diet - 4Recommend a release from home health care related to noncompliance - Solution 3 A client has chronic renal failure and is being treated at home. During weekly home visits, which factor is the most accurate indicator of fluid balance? 1Trends in daily weights - 2Skin turgor over at least two areas of the body 3Changes in mucous membrane moistness 4Difference between intake and output - Solution 1Trends in daily weights - The client is receiving a thrombolytic agent to open a clot-occluded coronary artery following a myocardial infarction. Which finding would be the greatest concern and should be immediately reported to the registered nurse? 1Hematemesis - 2Pink-tinged saliva 3Serosanguinous drainage from the IV site 4Slight rust-colored urine - Solution 1Hematemesis - The nurse is caring for a postoperative client following a closed reduction of distal tibia and mid-femur fractures. The client has a long leg plaster cast. Thirty-six hours after surgery, the client suddenly becomes confused, short of breath and spikes a temperature of 103 F (39.4 C). What should be the first action by the nurse? 1Check the distal circulation of the casted extremity 2Obtain the pulse oximetry reading 3Measure the client's blood pressure in the supine and Fowler's positions 4Check the orientation to time, place and person - Solution 2 The client has an order for intermittent gastrostomy tube (G-tube) feedings. What is the priority action by the nurse to accurately assess correct placement of the G-tube? 1Listen for active bowel sounds in all four quadrants 2Measure the pH of stomach content aspirate 3Auscultate the abdomen while instilling 10 mL of air into the G-tube 4Measure the length of tubing from the insertion site each shift - Solution 1Listen for active bowel sounds in all four quadrants 2Measure the pH of stomach content aspirate - 3Auscultate the abdomen while instilling 10 mL of air int1Listen for active bowel sounds in all four quadrants 2Measure the pH of stomach content aspirate - 3Auscultate the abdomen while instilling 10 mL of air into the G-tube 4Measure the length of tubing from the insertion site each shifto the G-tube 4Measure the length of tubing from the insertion site each shift The client is diagnosed with infective endocarditis of the tricuspid valve. Which finding suggests a complication of this condition? 1Pronounced wheezes 2Pain on deep inspiration 3Sudden back pain 4Sudden dyspnea - Solution 4 A client is scheduled for a percutaneous transluminal coronary angioplasty (PTCA). What should the nurse understand about the purpose of this procedure? 1The surgical repair of a diseased coronary artery 2An noninvasive radiographic examination of the heart 3A process to compress arterial plaque to improve blood flow 4The placement of an automatic internal cardiac defibrillator - Solution 3 A 2 day-old infant born with spina bifida and meningomyocele is recovering after an initial surgery. As the nurse accompanies the grandparents for their first visit since the child's birth, which of these responses might the nurse expect from the grandparents? 1Anger 2Disbelief 3Depression 4Frustration - Solution 2 The ICU nurse works in a rural hospital that has a remote electronic ICU monitoring system (eICU.) What is one of the best reasons for having access to an eICU? 1An ICU nurse and intensivist remotely monitor ICU clients around the clock 2An ICU nurse is on-call to solution questions when needed 3Clients can ask the intensivist for a second opinion 4Less staff is needed on site when a remote eICU is available - Solution 1 A child has severe burns to the lower extremities. A diet high in protein and carbohydrates is recommended. The nurse should care for this client with the knowledge that the most important reason for such a diet is to achieve which result? 1Provide a well-balanced nutritional intake 2Promote healing and strengthen the immune system 3Spare protein catabolism to meet metabolic and healing needs 4 stimulate increased peristalsis and nutrient absorption - Solution 3 A nurse is reinforcing information about the administration of an albuterol inhaler to an adult diagnosed with asthma. What should be the priority comment made by the nurse? 1"Use this medication at bedtime to promote rest." 2"Notify the health care provider if your canister lasts only two weeks." 3"Inhale this medication after other asthma sprays." 4"Discontinue the inhaler if you are dizzy." - Solution 2 An 80 year-old client is hospitalized for a chronic condition. The client informs family members that a living will has been prepared and the client wants no life-prolonging measures performed. The client's condition deteriorates and the client becomes unresponsive. Which of the following nursing actions is most appropriate? 1Notify the attending physician 2Consult the charge nurse and prepare to transfer the client to an intensive care unit 3Call the rapid response team 4Contact the family member indicated in the admission forms - Solution 1 The nurse is caring for a client who has just been admitted to the inpatient mental health unit with severe depression. Which concern should be a priority of care? 1Safety 2Elimination 3Rest 4Nutrition - Solution 1 A client is scheduled to have blood drawn for serum cholesterol and triglycerides tomorrow morning. What information should the nurse reinforce to the client about the test? 1"Be sure to eat a fat-free diet until the test, and drink lots of water." 2"Stay at the laboratory so that two blood samples can be drawn an hour apart." 3"Do not eat or drink anything but water for 12 hours before the blood test." 4"Have the blood drawn within two hours of eating breakfast." - Solution 3 The nurse is caring for a hospitalized adolescent. The nurse recognizes that which of these concerns will be the greatest for a hospitalized adolescent? 1Restricted physical activity 2Separation from family 3Altered body image 4Unrelieved pain - Solution 3 In checking a postpartum client, the nurse palpates a firm fundus. However, the nurse also observes a constant trickle of bright red blood from the vaginal opening. What should the nurse suspect? 1Retained placenta 2Clotting disorder 3Vaginal lacerations 4Uterine atony - Solution 3 A client diagnosed with gout is admitted with severe pain, swelling and redness in the proximal toe joint of the right foot. The nurse should anticipate that the plan of care would include which focus? 1High-protein diet 2Fluid intake of at least 3000 mL/day 3Acetaminophen for inflammation 4Hot compresses to affected joints - Solution 2 A 6 year-old child is hospitalized with findings of moderate edema, gross hematuria and mild hypertension associated with the diagnosis of acute glomerulonephritis (AGN). Which nursing intervention would be appropriate for this client? 1Weigh the child twice per shift 2Relieve boredom through physical activity 3Institute seizure precautions 4Encourage the child to eat protein-rich foods - Solution 3 A mother asks about expected motor skills for her 3 year-old child. Which activity should the nurse discuss as normal at this age? 1Riding a tricycle 2Tying shoelaces 3Jumping rope 4Playing hopscotch - Solution 1 The nurse is assessing a client who has been treated long-term with glucocorticoid therapy. Which finding might the nurse expect? 1Jaundice 2Peripheral edema 3Buffalo hump 4Increased muscle mass - Solution 3 A client diagnosed with autism begins to eat with both hands. The nurse can best handle the behavior by using which approach? 1Commenting "I believe you know better than to eat with your hands." 2Removing the food and stating "You can't have any more food until you use the spoon." 3Jokingly stating "Well, I guess fingers sometimes work better than spoons." 4Placing the spoon in the client's hand and stating "Use the spoon to eat your food." - Solution 4 The client is diagnosed with heart failure and oral digoxin is prescribed. What is the priority nursing assessment for this medication? 1Monitor serum electrolytes and creatinine 2Measure apical pulse prior to administration 3Maintain accurate intake and output ratios 4Monitor blood pressure every 4 hours - Solution 2 A 16 month-old child has just been admitted to the hospital. As the nurse assigned to this child enters the hospital room for the first time, the toddler runs to the mother, clings to her and begins to cry. What should be the next action of the nurse? 1Arrange to change client-care assignments 2Discuss with the parent the appropriate use of "time-out" 3Explain to the mother that the child needs extra attention 4Explain to the parent that this behavior is expected - Solution 4 The mother of a hospitalized 2 year-old child asks a nurse's advice about the child's screaming every time the mother gets ready to leave the hospital room. The best advice by the nurse would include which approach? 1Explain that this behavior will stop with in a few days 2Suggest that the mother "sneak out" of the child's room when the child is asleep 3Request for the mother to remain with the child at all times 4Help the mother understand that this is a normal response to hospitalization - Solution 4 A client has a percutaneous endoscopic gastrostomy (PEG) tube that is used to administer feedings and medications. Which nursing action is best to ensure patency of the tube? 1Encouraging the client to cough to relieve abdominal bloating prior to or following a feeding 2Adequately flushing the tube with water before and after use 3Completely crushing all medications prior to administration 4Squeezing the tube to dislodge obstructions - Solution 2 A nurse is observing an 8 month-old client. Which behavior would the nurse anticipate the infant to be able to display? 1Pull up to stand 2Use a spoon 3Say two words 4Sit without support - Solution 4 A client is admitted with newly diagnosed hypothyroidism. A nurse would expect the client to exhibit which finding until the client achieves a euthyroid state with therapy? 1Heat intolerance 2Diarrhea 3Tachycardia 4Lethargy - Solution 4 The licensed practical nurse is caring for a client with advanced cirrhosis of the liver. Which finding should receive immediate follow-up by the charge nurse? 1Jaundice 2Respiratory function 3Bladder control 4Peripheral sensation - Solution 2 There's a new order to apply one-inch of nitroglycerin paste to the client's chest every 12 hours, but the medication is not in the automatic medication dispensing system's drawer for this client. What should the nurse do next? 1Use another client's nitroglycerin paste until pharmacy sends a tube for this client 2Substitute an equivalent amount of nitroglycerin sublingual spray from the crash cart 3Call the pharmacy to send up a tube of nitroglycerin paste 4Call the prescriber and ask to substitute a different formulation of nitroglycerin - Solution 3 A nurse is caring for a child being discharged after a tonsillectomy. Which instruction is appropriate for the nurse to reinforce with the parents? 1Report a persistent cough to the health care provider 2The child can return to school in four days 3Administer chewable medication for pain 4The child may gargle as necessary for discomfort - Solution 1 An 80 year-old client is scheduled for a cardioversion. The nurse is reviewing the client's medication administration records for the previous 24 hours. Which medication would prompt the nurse to notify the health care provider? 1Diltiazem (Cardizem) 2Digoxin (Lanoxin) 3Nitroglycerine ointment 4Metoprolol tartrate (Toprol XL) - Solution 2 A nurse has reinforced teaching for a client who is being discharged after an arterial revascularization of the right lower extremity. Which statement made by the client is incorrect and requires further discussion with the nurse? 1"Smoking will decrease the circulation to my leg" 2"Coughing and deep breathing are important for a few weeks." 3"I will put my right leg through a full range of motion." 4"I might feel a throbbing pain in my right leg." - Solution 3 The nurse is assisting in the application of a plaster cast for a client with a broken arm. Which action is a priority? 1The cast material should be dipped several times into warm water 2The cast should be uncovered until it dries 3The casted extremity should be placed on a supporting surface 4The wet cast should be handled with the palms of hands for 48 to 72 hours - Solution 4 The client undergoes a gastrectomy. Several hours after surgery, the nasogastric (NG) tube stops draining. What action does the LPN anticipate the RN will take first? 1Reposition the tube 2Increase the amount of suction 3Gently irrigate the tube with sterile normal saline 4Notify the surgeon - Solution 3 A 12 year-old child, admitted with a broken arm, is waiting for a scheduled surgery. The nurse finds the child crying and unwilling to talk. What would be the most appropriate initial response by the nurse? 1Reassure the child that the surgery will go fine with no problems 2Provide privacy with encouragement to work through feelings 3Distract the child with a choice of activities to do while waiting for surgery 4Make arrangements for friends to visit as soon as possible - Solution 2 A nurse is caring for a client with a sigmoid colostomy. The client requests assistance in removing the flatus from a one-piece drainable ostomy pouch. Which intervention should the nurse use? 1Pierce the plastic at the top of the ostomy pouch with a pin to vent the flatus 2Pull the adhesive seal around the ostomy pouch to allow the flatus to escape 3Open the bottom of the pouch to allow the flatus to be expelled 4Assist the client to ambulate to reduce the flatus in the pouch - Solution 3 A client returns from the operating room after a right orchiectomy. What is the priority nursing intervention during the immediate postoperative period? 1Manage postoperative pain 2Maintain fluid and electrolyte balance 3Control bladder spasms with PRN medication 4Ambulate the client within a few hours after surgery - Solution 1 The nurse enters the room of a postpartum mother and observes the baby lying at the edge of the bed while the mother sits in a chair. The mother states, "This is not my baby, and I do not want it." How should the nurse respond? 1"What a beautiful baby! The baby's eyes are just like yours." 2"This is a common occurrence after birth. Let's talk about how to accept the baby." 3"You seem upset, tell me about how you are feeling"? 4"Many women have postpartum blues and need some time to love the baby." - Solution 3 The client calls the clinic nurse and reports nausea, headache and fatigue. The client also reports seeing yellow halos around lights. What is the best response by the nurse? 1"Do your eyes appear bloodshot and is there any itching?" 2"Tell me about your prescription for digoxin. Are you still taking the medication?" 3"Call back in a week and schedule an appointment if your symptoms don't improve." 4"Is there anyone else at home who has the same symptoms?" - Solution 2 A client is admitted to the mental health inpatient unit with a diagnosis of major depression after a suicide attempt. In addition to expressions of sadness and hopelessness, the nurse anticipates observing which characteristics? 1Meticulous attention to hygiene, grooming 2Anxiety, hostility 3Psychomotor retardation, agitation 4Guilt, indecisiveness - Solution 3 A nurse is assigned to care for a 10 month-old infant with the new diagnosis of anemia. Which of these findings should the nurse anticipate? 1Behavior consistent with hyperactivity 2Slow heart rate when sleeping 3Pale mucosa inside the mouth 4High hemoglobin level - Solution 3 A client becomes acutely short of breath with an SpO2 (oxygen saturation) of 82%. Which oxygen delivery system should the nurse apply that would provide the highest concentrations of oxygen to the client? 1Simple face mask 2Partial rebreather mask 3Venturi mask 4Non-rebreather mask - Solution 4 A nurse gathers data related to delayed gross motor development in a 3 year-old client. Which observation by the nurse should confirm this finding? 1Cannot ride a bicycle 2Cannot catch a ball 3Cannot skip on alternate feet 4Cannot stand on one foot - Solution 4 A client is admitted to the hospital with a history of confusion. The client has difficulty remembering recent events and becomes lost when outside of the home. Which statement would provide the best reality orientation for this client? 1"Hello. My name is Elaine Jones and I am your nurse for today." 2"Good morning. You're in the hospital. I am your nurse Elaine Jones." 3"How are you today? Remember, you're in the hospital. I will be your nurse all day. My name is Elaine Jones." 4"Good morning. I am Elaine Jones, your nurse. Do you remember where you are?" - Solution 2 A client is diagnosed with a Salmonella infection. What is a primary nursing intervention to be taken to minimize the transmission of disease from this client? 1Double glove when in contact with feces or emesis 2Wash hands thoroughly before and after any client contact 3Wear gloves when disposing of contaminated linens 4Use gloves when in contact with body secretions - Solution 2 A 6 month-old infant is being treated for developmental hip dysplasia and has been placed in a hip spica plaster cast. Which discharge information is important for the nurse to reinforce with the parents? 1Turn the baby every two hours using the abduction stabilizer bar 2Check frequently for swelling in the baby's feet 3Gently rub the skin with a cotton swab to relieve itching 4Place favorite books and push-pull toys in the crib - Solution 2 A nurse is talking to parents about the side effects of routine immunizations. Which finding should the nurse reinforce about calling the health care provider if it occurs within 24 to 48 hours after a routine immunization? 1Localized tenderness at the injection site 2Tympanic temperature of 104 F (40 C) 3Some irritability and fussiness 4Swelling at the injection site - Solution 2 A 28-year-old is transferred to the emergency department (ED) via ambulance with a traumatic head injury. The client is awake and reports having a headache and some amnesia. What are the priority nursing interventions for this client? (Select all that apply.) - Solution Correct Response Assess vital signs and neurological function Assess the airway Prepare for CT imaging of the head Assess the wound for presence of drainage or bruising on the head A client exhibits many delusional thoughts. As the nurse assists the client to prepare for breakfast, the client comments, "Don't waste good food on me. I'm dying from this disease I have." Which response by the nurse would be the best? 1"None of the laboratory reports show that you have any physical disease." 2"Try to eat a little bit. Breakfast is the most important meal of the day." 3"I know you believe that you have an incurable disease." 4"What has your primary health care provider told you?" - Solution 3 The family member tells an admitting nurse that the client values the practice of Chinese medicine. The nurse must understand that for this family and client a priority goal should take which focus? 1Achieve harmony 2Respect life in old age 3Maintain energy balance 4Restore yin and yang - Solution 4 The nurse is reinforcing dietary instructions to the parents of a child diagnosed with cystic fibrosis. The nurse will emphasize which of the following characteristics of this diet? 1A gluten-free diet, avoiding foods that contain wheat, rye and barley 2Balanced, high calorie diet with extra fat, salt, protein and calcium 3Foods low in sodium, potassium and phosphorus 4Carbohydrate counting, selecting foods from the bread/starch, fruit, or milk group - Solution 2 The nurse works in a psychiatric inpatient setting. What information should the nurse be aware of as one of the most frequent reasons for suicide in adolescents? 1Progressive failure to adapt to peer pressure 2Reunion wish or a fantasy of some sort 3Feelings of anger or hostility toward others 4Feelings of alienation or isolation from peers - Solution 4 When a client returns from surgery after an open reduction with cast application for a femur fracture, a small blood stain is noted on the cast by the nurse. Four hours later, the nurse observes that the stain has doubled in size. What is the initial action for the nurse to take at this time? 1Ask the family members to call you when they notice the spot getting larger 2Record the findings in the nurse's notes 3Outline the spot with a pen and note the time and date on the cast 4Report the finding to the registered nurse (RN) charge nurse - Solution 3 The nurse is discussing an illness with a 10 year-old child. What should the nurse keep in mind about this child's ability to understand the information at this stage of development? 1Makes simple association of ideas 2Bases conclusions on abstract thinking I3nterprets events from own perspective 4Thinks logically to organize facts - Solution 4 The nurse calls for help after finding an unresponsive adult client in a hospital room. What action should the nurse take next for the client who has no pulse and is not breathing? 1Open the airway and deliver two breaths followed by 30 compressions The client is seen in the emergency one day after falling in his bathroom at home. The client reports having "a few drinks" prior to the fall. Which finding requires the nurse's immediate attention? 1Bruise behind one ear 2Blurred vision 3Nausea and vomiting 4Headache - Solution 1 Diagnosed with heart failure, the client had an implantable cardioverter- defibrillator (ICD) implanted several years ago. The client now has end- stage heart failure and is receiving home hospice care. Which end-of-life care option could have the greatest impact on client comfort? 1Encouraging the client to sit upright in bed 2Confirming advanced directives and plans for resuscitation 3Deactivating the implantable cardioverter-defibrillator (ICD) 4Assisting the client to eat several small meals - Solution 3 The client is prescribed alendronate (Fosamax). What information about medication administration should the nurse be sure to reinforce? 1Take on an empty stomach 2Take with milk, two hours after meals 3Take with calcium 4Take after meals - Solution 1 A couple experienced a miscarriage at seven months of pregnancy. The nurse makes a home visit one week after discharge from the hospital. What intervention should the nurse emphasize to the couple during the home visit? 1Plan another pregnancy as soon as possible 2Seek causes of the death for prevention purposes 3Focus on the other healthy children at home 4Discuss feelings with support persons and each other - Solution 4 A nurse is reinforcing information to a mother who is breast-feeding a newborn infant diagnosed with oral candidiasis. Which statement by the mother would be incorrect and indicate a need for reinforcement of information? 1"The therapy can be discontinued when the spots disappear." 2"I will boil the nipples and pacifiers for 20 minutes." 3"Expressed breast milk should be used immediately or frozen." 4"Nystatin should be given four times a day after my baby eats." - Solution 1 The nurse is to administer meperidine 100 mg, atropine 0.4 mg, and promethazine 50 mg IM to a client preoperatively. Which action should the nurse take initially? 1Place the bed in the low position 2Instruct the client to remain in bed 3Place the call bell within reach 4Have the client empty the bladder - Solution 4 The parents of a school-age child are providing information to the nurse about their child. Which of these health issues should the nurse recognize as a finding that could suggest type 1 diabetes? 1Being a picky eater 2Weight gain 3Bedwetting 4Oily and acne-prone skin - Solution 3 An adolescent client arrives at a clinic three weeks after the birth of her first baby. She tells the nurse she is very worried about not returning to her pre- pregnancy weight. Which approach should the nurse take first? 1Review the client's pattern of weight gain over the past year 2Encourage her to talk about her self-image 3Give her several pamphlets on postpartum nutrition 4Ask the mother to record her diet for the next few weeks - Solution 2 A nurse is caring for a client admitted with the diagnosis of suspected Legionnaire's disease. Which finding would require the nurse's immediate attention? 1Dry mouth with frequent requests for water 2Abdominal gas pains that are severe and disappear suddenly 3 Increased use of accessory muscles of breathing 4Difficulty sleeping due to leg cramps - Solution 3 Legionnaire's disease is a type of acute bacterial pneumonia. Increased use of accessory breathing muscles and labored breathing are indicators of respiratory distress and should be reported immediately. The nurse is caring for a client with congestive heart failure. Which task can the nurse delegate to the unlicensed assistive person (UAP)? 1Record and report the client's intake and output. 2Inspect and report peripheral IV site status. 3Palpate for edema in the lower extremities. 4Evaluate understanding of prescribed medications. - Solution 1 A client refuses to take the medication prescribed because the client prefers to take an herbal preparation instead. What is the first action the nurse should take? 1Discuss with the client to find out about the preferred herbal preparation 2Explain the importance of the medication to the client 3Contact the client's health care provider about the refusal 4Report the behavior to the charge nurse - Solution 1 The nurse is caring for a group of clients when a fire alarm sounds in the hospital cafeteria. What should the nurse do next? 1Close all doors in the area. 2Find the fire extinguisher. 3Remove oxygen devices. 4Begin evacuating the clients. - Solution 1 The licensed practical nurse (LPN) is caring for a client with an order that reads, "morphine sulfate 2 mg IV push every 3 to 4 hours as needed for pain." There are no other licensed persons working that shift. Which action should the nurse take? 1Give the medication orally and follow-up with the health care provider. 2Hold the medication and contact the health care provider. 3Administer the prescribed dose as ordered. 4Check with the pharmacist to verify the order. - Solution 2 The nurse is providing care for a client who was recently diagnosed with end-stage heart failure. The client does not have advance directives in place. Which of the following statements by the nurse would be appropriate? (Select all that apply.) - Solution "Have you thought about what you want done as your disease progresses?" "What does your family know about your condition and prognosis?" "Have you discussed your wishes regarding resuscitation with your health care provider?" A client with a musculoskeletal disorder has been newly fitted with a lower limb orthotic. Which activity can the nurse delegate to the certified nursing assistant (CNA)? 1Provide instruction to the client for ambulation with the orthotic. 2Monitor the client's response to moving with the orthotic. 3Check the client's skin for any redness or irritation from the orthotic. 4Assist with transferring the client from the bed to the chair. - Solution 4 Upon completing a review of a 27-year-old client's admission documents, the nurse identifies that the client does not have an advance directives. What action should the nurse take? 1Lecture the client on the importance of having advance directives. 2Inform the charge nurse to offer information about advance directives. 3Advance directives are not appropriate for this client due to the client's age. 4Refer this issue to the client's health care provider. - Solution 2 The home health nurse is visiting a client diagnosed with type 1 diabetes and osteoarthritis. The client has difficulty holding and using the prescribed insulin pen. The nurse should refer the client to which community resource person? 1Physical therapist 2Pharmacist 3Physical therapist 4Occupational therapist - Solution 4 Holding and using an insulin pen requires fine motor skills and good vision. A client with osteoarthritis (OA) might experience limited movement and pain in the joints of the fingers and hand. An occupational therapist can help a client improve the fine motor skills needed to prepare an insulin injection. An occupational therapist works with clients to perform tasks that are needed for smaller movements to maintain activities of daily living or for work. A client diagnosed with schizophrenia insists that the nurse explain the use and side effects of the medications prescribed for the client. What should the nurse understand before responding to the client? 1The psychiatrist will need to grant permission to discuss the client's medications. 2All clients have a right to be informed about their prescribed medications 3A decision to reinforce or not reinforce information about medications should be made by the nurse alone. 4It is too dangerous for clients who are diagnosed with schizophrenia to know about their medications. - Solution 2 The nurse asks another staff nurse to sign for wasting a partial-dose opioid injection, although the wasting was not witnessed by anyone. This type of request seems to be a pattern of behavior for this nurse. What is the most appropriate action for the second staff nurse to take? 1Report this request immediately to the nurse manager. 2Review the client's medication administration record (MAR) for past wastes. 3Ask the nurse's client if they witnessed the waste of the partial dose. 4Confront the nurse about suspected narcotics diversion. - Solution 1 A client diagnosed with bipolar disorder has been referred to social services for possible placement in a community halfway house after discharge. The social worker telephones the nurse and asks for information about the client's mental status and adjustment. What should the nurse do next to respond to this request? 1Go ahead and provide the information, since the client is ready for discharge. 2Inform the caller that this kind of information is never given over the telephone. 3Refer the social worker to the health care provider to obtain the requested information. 4Verify that the client's medical record includes the client's written consent to release information. - Solution 4 During a discussion about a living will, the client's son states, "I do not understand the need for a living will." What is the best response by the nurse? 1"Health care decisions can be made based on the client's wishes." 2"Specific instructions are listed for specific diseases." 3"A designated family member can make all decisions." 4"Do not resuscitate (DNR) orders are automatic under these conditions." - Solution 1 The client requests not to be interrupted before 10 am because it interferes with the client's time to meditate. What action shall the nurse take first? 1Document the client's request in the medical record. 2Meet with the client to formulate a mutually agreeable schedule. 3Notify the dietary department about the client's request. 4Adjust administration times for prescribed medications. - Solution 2 A client who recently experienced a stroke has an order to ambulate with assistance. Which statement by the nurse provides the best instructions to the unlicensed assistive person (UAP) who will assist the client to ambulate? 1"Have the client lift and move the walker out to arm's length, then walk into the walker." 2"If the client becomes dizzy while walking, ask the client to stop and take 10 fast, deep breaths." 3"As you assist the client to the chair, let me know if the client uses the quad cane correctly." 4"Stand on the client's strong side when you assist the client to the bathroom." - Solution 1 The person assisting the client to ambulate should walk on the client's weak side, NOT STRONG, side. The nurse is reviewing information about the health care organization's efforts to improve quality of care. Which of these statements best describes the goal of continuous quality improvement (CQI) in a health care setting? 1Perform actions based on reactive problem solving. 2Create a flow chart of department or staff interactions. 3Conduct chart audits for common error discovery. 4Improve the quality of care in a proactive manner. - Solution 4 The client is admitted with a diagnosis of hyperglycemia and poor glycemic control. Which task can the nurse assign to an unlicensed assistive person (UAP)? 1Check sensation in the extremities 2Observe for mental status changes every four hours 3Reinforce findings of hypoglycemia when the client asks 4Measure blood pressure, pulse and respirations - Solution 4 When walking past a client's room, the nurse hears an unlicensed assistive person (UAP) talking to another UAP. Which of these statements requires further intervention by the nurse? 1"I'll come back and make the bed after I go to the lab." on the wrong client. Which of the following actions are appropriate for the nurse to take? - Solution Mark the entry as "mistaken entry-wrong patient." Enter the time the error was discovered. The nurse is preparing a client for a colonoscopy and notes that the consent form has not been signed. Which of the following statements by the nurse are appropriate to make to the client? - Solution "Please tell me your full name and date of birth." "Do you have any questions about the colonoscopy?" "Describe what the health care provider told you about a colonoscopy." An outpatient client is scheduled to receive an oral solution of radioactive iodine. In order to reduce radiation exposure to others, which information should the nurse reinforce? 1No solid food may be eaten for six hours after ingestion. 2Urine and saliva will be radioactive for 24 hours after ingestion. 3Wash laundry separately and rinse twice in hot water. 4Wait for 48 hours to have grandchildren visit at home. - Solution 2 The client is diagnosed with active tuberculosis (TB) and the case has been reported to the local health department. The nurse understands that the most important reason for notifying the health department is: 1To ensure that treatment compliance will be monitored 2To trace and screen recent contacts the client had 3To maintain important disease outbreak statistics 4To track the incidence of tuberculosis cases - Solution 2 The parent of a toddler who is being treated for suspected poisoning asks, "Why is activated charcoal used?" What is the best response by the nurse? 1"When the poison is absorbed into the blood stream, the activated charcoal will neutralize it." 2"Activated charcoal binds with the poison to limit absorption in the digestive tract." 3"Activated charcoal causes vomiting, which will eliminate the poison from the body." 4"The activated charcoal will protect the kidneys from any long-lasting damage." - Solution 2 The parents of a toddler ask, "How long will our child have to sit in a car seat when riding in a car?" What would be the best response by the nurse? 1"Until the child is able to sit in a booster seat." 2"Until the child weighs 40 pounds." 3"Until the child outgrows the car seat." 4"Until the child is 50 inches tall." - Solution 3 The nurse has administered haloperidol 5 mg orally (PO) as needed (PRN) to a client with a diagnosis of schizophrenia. Which of the following behaviors justify use of this chemical restraint? - Solution The client is verbalizing a plan to harm another client. The client is expressing paranoid delusions. The client is experiencing command hallucinations. A community health clinic nurse is interviewing a client who is experiencing lightheadedness. The client reports a history of arthritis and is taking naproxen sodium for the pain. The client is pale, the blood pressure is 88/40, pulse is 114, respiratory rate is 22 and temperature is 98.2° F (36.7 C°). What additional information should the nurse solicit from the client? (Select all that apply.) - Solution frequency and amount used color of bowel movements bruising The nurse is discussing modifiable cardiac risk factors with a group of adult clients at a community center. Which topic should the nurse reinforce as the highest priority intervention? 1Increasing physical exercise 2Smoking cessation 3Stress management 4Weight reduction - Solution 2 The home health nurse is seeing a client diagnosed with type 2 diabetes. The client has a small foot ulcer that was debrided and requires daily dressing changes. Which intervention is most important for the nurse to implement to meet the goal of uncomplicated wound closure? 1Schedule regular visits to monitor wound healing. 2Involve the client in making decisions. 3Evaluate the client's understanding of appropriate foot care. 4Arrange for referral to a diabetic educator. - Solution 2 The client is in her first trimester of pregnancy. What major developmental task should the client accomplish during this stage of pregnancy? 1Viewing the fetus as a separate and unique being. 2Accepting the loss of physical intimacy. 3Resolving any fears related to giving birth. 4Accepting physical changes related to pregnancy. - Solution 4 A home health nurse is making an initial visit to a new client. What action should the nurse take first to meet the client's health needs? 1Identify community resources. 2Assist with meal planning. 3Evaluate the home for safety hazards. 4Identify the client's learning needs. - Solution 4 During a well-baby visit, the nurse is evaluating developmental milestones for the 7-month-old child. Which of these developmental activities should the child be able to perform? 1Sits without support 2Uses pincer grasp 3Says several words 4Drinks from a cup - Solution 1 The age at which a child typically develops the ability to sit steadily without support is around 7 to 8 months. Saying several words, drinking from a cup and using a neat pincer grasp are developmental milestones that most children do not reach until age 11 to 12 months. A client is forgetful and experiencing short-term memory loss. While collecting data about short-term memory loss, which action should the nurse take first? 1Ask the client to state his date of birth. 2Confirm that the client's hearing is intact. 3Observe the client while performing an activity. 4Ask the client to name the current U.S. president. - Solution 2 During the physical inspection of a client, the nurse notes a pulsating mass in the client's periumbilical area. Which action should the nurse take next? 1Measure the length of the mass. 2Auscultate the area. 3Palpate the area. 4Percuss the area. - Solution 2 illness. These are sometimes described as features that are "added" by the illness. In contrast, negative symptoms are those that reflect a decrease in normal functions, or abilities that have been "taken away." Positive symptoms of schizophrenia include delusions, hallucinations, hyper vigilance and disorganized thinking. The nurse is providing care for a client who has been diagnosed with terminal cancer. The nurse notes that the client's wife is not visiting very often. When she does visit the client, she only stays for a brief time, stands in the corner and does not approach the client during interactions. Which of the grieving processes is the client's wife most likely experiencing? 1Disenfranchised grief 2Anticipatory grief 3Perceived loss 4Death anxiety - Solution 2 anticipatory grief is the family member becomes distant and detached from the client and the client feels isolated and alone. Death anxiety is worry or fear related to dying that may be seen with a grieving child. Disenfranchised grief is when the individual cannot acknowledge the loss, perhaps because of an unrecognized loss, such as an abortion or a suicide. Perceived loss is a loss that cannot be verified by others such as a loss of self-esteem or a loss of control. The nurse is caring for a postpartum Latina client who keeps declining the hospital food because it is "cold." What action should the nurse take initially? 1Send the food to be reheated. 2Encourage the client to eat for strength. 3Ask the client what foods are acceptable. 4Consult with the dietitian as soon as possible. - Solution 3 An adolescent client is paralyzed from the waist down after being involved in a motor vehicle accident. Which client statement would indicate to the nurse that the client is using repression as an ego defense mechanism? 1"It's all the other driver's fault! They were driving too fast." 2"I don't remember anything about what happened to me." 3"My parents are heartbroken about my situation." 4"I know that I will walk again one day." - Solution 2 Repression is the unconscious and involuntary forgetting of painful events, ideas and conflicts. The nurse is working with a couple who is experiencing intense anxiety after their home was completely destroyed by a fire. The nurse should implement which initial intervention? 1Suggest finding an apartment with a sprinkler system. 2Explore the couple's feelings of grief and loss. 3Determine what community housing resources are available. 4Provide a brochure on relaxation and stress relief. - Solution 3 The couple has experienced a crisis, i.e., sudden loss event that has resulted in disequilibrium. The most important initial crisis intervention focuses on identifying resources and obtaining assistance for housing and other immediate needs. The nurse is evaluating a client who is being physically abused by the client's domestic partner. The client states, "I need a little time away." Which is the most likely response from the partner for which the nurse should prepare the client? 1Fear of rejection, resulting in increased rage toward the client 2Relief over a separation as a way to have some personal time 3Acceptance and understanding that the relationship is in trouble 4A new commitment to seek counseling to assist with problems - Solution 1 A client is admitted to the medical-surgical unit following a motor vehicle accident. Twelve hours after admission the client becomes diaphoretic, tremulous and irritable, and the client's pulse and blood pressure are elevated. The client states to the nurse, "I have to get out of here." What is the most likely cause for the client's symptoms and behavior? 1Dissatisfaction with hospital care 2Anxiety related to being hospitalized 33hock related to the injuries 4Early stage of alcohol withdrawal - Solution 4 signs and symptoms of alcohol withdrawal, such as sweating, tremors, hyperactivity, hypertension and tachycardia. The client most likely wants to leave the hospital to obtain alcohol. The client must be monitored very closely for progression to more severe alcohol withdrawal symptoms, including seizures and delirium tremens (DTs). A client who is taking duloxetine asks the nurse if the medication treats depression or diabetes. What is the best response from the nurse? 1"Duloxetine is used to treat depression but can also be used to lower blood sugar levels." 2"Duloxetine is used to treat depression but can be used to treat pain that can occur in people with diabetes." 3"Duloxetine is not prescribed for either depression or diabetes." 4"Duloxetine is used to treat diabetes but can also be used to treat depression." - Solution 2 Duloxetine is a selective serotonin and norepinephrine reuptake inhibitor (SNRI) that can be used to treat depression but also can be used to treat pain associated with diabetic neuropathy. The nurse is caring for a female client with a body mass index (BMI) of 45. Which conditions should the nurse plan to discuss with the client due to the risks associated with her weight? (Select all that apply.) - Solution obstructive sleep apnea gallstones coronary artery disease breast cancer HYPERTHYROIDISM IS NOT ASSOCIATED WITH BEING OVERWEIGHT OR BMI The nurse is caring for a client diagnosed with substance use disorder (SUD). The client states, "I just drink occasionally. I don't know why my wife and the judge think that I need to be in an alcohol treatment program." Which of the following behaviors are consistent with SUD? (Select all that apply.) - Solution Prone to act impulsively Insecurity in relationships Craving and inability to abstain from alcohol The nurse is caring for a client who has a history of heavy alcohol use. Which findings would indicate that the client is probably experiencing delirium tremens (DTs)? 1Chest pain, nausea, diaphoresis and tachycardia 2Nausea, vomiting, bloody stools and hypotension 3Headache, blurred vision, garbled speech and hypertension 4Excitability, disorientation, tremors and tachycardia - Solution 4 A home health nurse is caring for a client diagnosed with late-stage, Lewy body dementia (LBD). The nurse is meeting with the client's family to discuss options for care of the client. What is the initial question the nurse should ask to assist the family with their decision-making process? 1"What is your opinion of nursing homes or assisted living facilities?" 2"Is your parent currently taking over-the-counter (OTC) or prescription medications?" 3"Are you able to assist with the care of your parent in any manner?" 4"What type of assistance does your parent require?" - Solution 4 The nurse is caring for a client with paraplegia due to a spinal cord injury at the T-7 level. Which nursing intervention should be a priority for this client? 1Obtain a pressure-reducing mattress for the client's bed. 2Observe the client performing self-catheterization correctly. 3Consult with the discharge planner about equipment the client's needs at home. 4Encourage the client to increase intake of fluids and high-fiber foods. - Solution 1 The nurse is evaluating the plan of care for a client with osteoporosis. What type of activity should the nurse reinforce for this client? 1Enroll in a kickboxing class twice a week. 2Walk for 30 minutes, 3 to 5 times a week. 3Participate in swimming lessons three times a week. 4Go jogging 5 to 7 times a week. - Solution 2 Teach the client (or reinforce teaching) that walking for 30 minutes, 3 to 5 times a week, is the single most effective exercise for osteoporosis prevention. The nurse is caring for child diagnosed with celiac disease. Which of the following foods would be an appropriate snack choice for this child? 1A cup of cereal 2A slice of wheat bread 3A cup of yogurt 4An oatmeal cookie - Solution 3 A client is on NPO status and has a nasogastric (NG) tube in place, connected to low-intermittent suction, to help resolve a small bowel obstruction. Which nursing intervention should the nurse implement for this client? 1Allow the client to melt ice chips in their mouth. 2Provide oral care at least every 2 to 4 hours. 3Swab the client's mouth, using glycerin swabs. 4Provide the client mints to freshen their breath. - Solution 2 The nurse is caring for an adult client who suffered second degree burns over 25% of their body in a house fire. Which observation best indicates that fluid resuscitation has been effective? 1Elastic, nontenting skin turgor 2Moist oral mucus membranes 3Urine output of 35 mL per hour 4No reports of thirst - Solution 3 The goal is to maintain an hourly urine output of 0.5 mL/hour (about 30 mL/hour) for the average adult. Which of the following actions by the nurse indicates a need for additional education on the prevention of health care-associated infections (HAIs)? 1The nurse uses their own stethoscope to assess the lung sounds of a client placed on contact precautions for Methicillin-resistant Staphylococcus aureus (MRSA) infection. 2The nurse calls the health care provider (HCP) to request the removal of the indwelling urinary catheter for a two days postoperative client. 3The nurse cleanses hands with soap and water for 60 seconds after caring for a client with Clostridium difficile (C. difficile) infection. 4The nurse wears a gown and gloves when providing perineal care to a client with Vancomycin-resistant Enterococci (VRE) infection. - Solution 1 A client has been diagnosed with dysphagia due to a stroke. What nursing intervention should the nurse implement for this client? 1Instruct the client to tilt their head back while swallowing. 2Position the client in an upright position while they are eating. 3Assist the client to drink through a straw. 4Instruct the client to use sips of water to help wash down food. - Solution 2 A client is transferred from the postanesthesia care unit (PACU) to the medical-surgical unit after an appendectomy. Which action should the nurse on the medical-surgical unit perform first? 1Ask the client about pain. 2Orient the client to the unit. 3Review the postoperative orders. 4Take the client's vital signs. - Solution 4 The nurse is evaluating the effectiveness of a bowel training program for a client with chronic constipation. Which statements made by the client should the LPN/VN report to the RN for additional teaching? - Solution Bowel training programs are designed to return defecation to normal. Fluid intake should be 2.5 to 3 liters per day. The client should increase fiber in their diet, and intake hot drinks just prior to their normal bowel elimination time to facilitate normal bowel function. A suppository treatment should be administered about half an hour before the client's normal bowel elimination time—inserting it just prior to bedtime will disturb the client's sleep pattern. The client should be provided with privacy for about 30 to 40 minutes and should sit on a commode or bedpan whenever they have the urge to defecate. An obese client tells the nurse, "I just started a diet and I am eating no more than 800 calories a day." What information should the nurse reinforce with the client? 1Very low-calorie diets often have severe and irreversible side effects. 2Very low-calorie diets are adequate if balanced with fruits and vegetables. 3Very low-calorie diets are intended for short-term use only. 4Very low-calorie diets are appropriate for long-term weight management. - Solution 3 A 2-year-old child is brought to the pediatrician's office by the parents, who report that the child has been having diarrhea for two days. What nutritional information should the nurse provide to the parents? 1Keep the child fasting, give them nothing to eat, and return the next day. 2Give the child only clear liquids and gelatin for 24 hours. 3Continue a regular diet and add electrolyte replacement drinks. 4Give the child bananas, apples, rice and toast as tolerated. - Solution 3 The nurse is providing care to an older adult client diagnosed with bilateral pneumonia. Which intervention should the nurse implement to best promote the client's comfort? 1Encourage visits from family and friends. 2Keep conversations short. 3Increase the client's oral fluid intake. 4Monitor vital signs frequently. - Solution 2 3The client has a history of acid reflux disease. 4The client has a history of urinary retention. - Solution 2 they are excreted by glomerular filtration. Aminoglycosides are nephrotoxic and requires close monitoring of renal function. A client with chronic kidney disease should not receive this medication. The nurse in a long-term care facility is preparing to administer medications. Which physiological changes does the nurse know will affect medication pharmacokinetics in older adults? 1Due to an increase in glomerular filtration rates, medications are excreted more rapidly. 2Due to a decrease in gastric emptying, higher medication doses are prescribed. 3Due to a decrease in renal drug excretion, a greater risk for adverse medication effects exist. 4Due to an increase in metabolism, medications are prescribed more frequently. - Solution 3 The nurse prepares to administer a liquid medication to an infant. At the bedside, the parent states that the infant does not like to take medications. Which action should the nurse perform to ease the medication administration? 1Use an oral syringe to administer the medication, alternating with a pacifier. 2Mix the liquid medication with a full bottle of formula. 3Give half the dose now and the remaining amount in an hour. 4Ask the health care provider (HCP) to switch the medication to an injection. - Solution 1 A client is admitted with deep vein thrombosis (DVT). The health care provider (HCP) orders the immediate administration of an intravenous bolus of heparin sodium 200 units/kg . The client weighs 187 lbs. How many mL should the nurse draw up from the supplied 10 mL vial that contains 5,000 units per mL? Do not round. - Solution 3.4 The nurse has given discharge instructions to a client who suffers from sensory neuropathy due to diabetes. The client was prescribed gabapentin. Which of the following statements indicates that the client understands the nurse's instructions regarding the medication? 1"I can stop taking the medication at any time." 2"It is safe to take extra doses if my pain becomes worse." 3"The medication might cause me to have insomnia." 4"My doctor prescribed it for the pain in my legs." - Solution 4 The nurse is reviewing medication orders for a client who has requested something for pain. In the process, the nurse finds a new written order for a pain medication. The health care provider (HCP) wrote, "Give APAP every six hours as needed for pain." Which parts of the medication order should the nurse clarify before administering the medication? - Solution route drug name dosage The nurse administers a medication to the wrong client. Which action(s) should the nurse take when the medication error is identified? (Select all that apply.) - Solution Notify health care provider Complete an incident report Monitor the client for adverse effects Document the error in the medical record A client recovering from hip replacement surgery is taking acetaminophen with codeine every three hours for pain. For which side effect should the nurse monitor the client? 1Diffuse rash 2Constipation 3Wheezing 4Hyperglycemia - Solution 2 A client is prescribed trimethoprim/sulfamethoxazole for recurrent urinary tract infections. Which statement by the nurse about this medication is correct? 1"You can stop the medication after five days." 2"Be sure to take the medication with food." 3"Drink at least eight glasses of water a day." 4"It is safe to take with oral contraceptives." - Solution 3 Unlike many other antibiotics, trimethoprim/sulfamethoxazole does not seem to affect hormonal birth control such as the pill, the patch or ring. The hospice nurse is visiting a client diagnosed with end-stage lung cancer and metastases to the bone. What should the nurse keep in mind when planning for effective pain management? 1Relief of pain will be achieved quickly. 2Pain therapy is based on the client's report of pain. 3High doses of opioid analgesics will be required. 4The client will most likely become addicted. - Solution 2 The nurse is discharging a client who is at risk for venous thromboembolism (VTE). The client is prescribed enoxaparin. Which instruction should the nurse provide to this client? 1"Notify your health care provider if your stools appear tarry or black." 2"You should massage the injection site for better absorption." 3"An intravenous (IV) catheter will be placed to administer the medication." 4"You must have your partial thromboplastin time (PTT) checked weekly." - Solution 1 As with any anticoagulant, enoxaparin carries the risk of bleeding. Clients should be instructed to report the presence of tarry stools, bleeding gums, hematuria, ecchymosis or petechiae to their HCP A client who has been diagnosed with Raynaud's disease and hypertension is prescribed nifedipine. For which side effect should the nurse monitor the client? 1Decreased urine output 2Facial flushing 3Cyanosis of the lips 4Increased pain in fingers - Solution 2 Nifedipine is a calcium channel blocker (CCB) used in the treatment of Raynaud's disease and hypertension by producing vasodilation. As a result of this vasodilating effect, facial flushing can occur. A postoperative client has a prescription for acetaminophen with codeine for pain relief. The nurse understands which action to be the primary purpose of this drug combination? 1Faster onset of action 2Minimized side effects 3Enhanced pain relief 4Prevents tolerance - Solution A client diagnosed with tuberculosis is prescribed rifampin and isoniazid. Which information should the nurse include when reinforcing information about these medications? 1"You may have occasional problems sleeping." ill may become temporarily confused while taking H2 blockers, especially cimetidine. A client at risk for a stroke has been prescribed clopidogrel. Which information is most important for the nurse to reinforce with the client? 1"You must take the medication on an empty stomach." 2"If you miss a dose, take a double dose the next day." 3"You must have your lab tests checked weekly." 4"You must stop the medication a week before your surgery." - Solution 4 Clopidogrel is an oral antiplatelet drug with similar effects to aspirin. The drug is taken for secondary prevention of myocardial infarction, ischemic stroke and other vascular events. Clopidogrel prevents platelet aggregation. Like all other antiplatelet drugs, clopidogrel poses a risk of serious bleeding. Clopidogrel should be discontinued 5 to 7 days before elective surgery. The nurse is reinforcing the correct use of a metered-dose inhaler (MDI) for a client newly-diagnosed with asthma. The client asks, "how will I know the canister is empty?" What is the best response by the nurse? 1"Drop the canister in water to observe if it floats." 2"Contact your pharmacy to find out when to obtain a refill." 3"Count the number of doses as the inhaler is used." 4"Shake the canister and listen for any fluid movement." - Solution 3 A client is prescribed furosemide and digoxin for heart failure. The nurse should monitor the client for which potential adverse drug effect? 1Pulmonary hypertension 2Acute arterial occlusion 3Cardiac dysrhythmias 4Acute kidney injury - Solution 3 Digoxin is a cardiac glycoside, or positive inotrope that increases myocardial contractility. By increasing contractile force, digoxin can increase cardiac output in clients with heart failure (HF). Furosemide is a potassium-wasting (loop) diuretic, prescribed to prevent fluid overload in clients with HF. Clients who take furosemide are at risk for developing hypokalemia. Potassium ions compete with digoxin and a low potassium level can cause digoxin toxicity, leading to lethal cardiac dysrhythmias. Therefore, it is imperative that potassium levels be kept within normal range (3.5 to 5 mEq/L) while taking digoxin. The nurse in an ambulatory clinic is speaking with the parents of a 2-year- old child diagnosed with acute otitis media. Which information is most important for the nurse to include in the instructions to the parents? 1The child must complete the entire course of the prescribed antibiotic. 2The child may be given a decongestant to relieve pressure on the tympanic membrane. 3The child should return to the clinic to evaluate effectiveness of the treatment. 4The child may be given acetaminophen or ibuprofen drops for pain. - Solution 1 The nurse is reinforcing teaching about levothyroxine for a client newly- diagnosed with hypothyroidism. Which information should the nurse make sure to reinforce about this medication? 1The medication may decrease the client's energy level. 2The medication will decrease the client's heart rate. 3The medication should be taken in the morning. 4The medication must be stored in a dark container. - Solution 3 A thyroid supplement, such as levothyroxine, should be taken on an empty stomach in the morning. Morning dosing minimizes the side effect of insomnia and an empty stomach facilitates absorption. Levothyroxine will cause an increase in the client's energy level and heart rate. A client received hydromorphone orally one hour ago. When the nurse enters the client's room, the client is unresponsive to verbal stimuli and has a respiratory rate of six. Which action should the nurse take next? 1Prepare for endotracheal intubation. 2Administer supplemental oxygen. 3Begin cardiopulmonary resuscitation. 4Prepare to administer naloxone. - Solution 4 A client has been prescribed alendronate for osteoporosis. Which of the following statements indicate the client understands how to safely take this medication? (Select all that apply.) - Solution Alendronate is a bisphosphonate used to treat osteoporosis. It can cause esophagitis or esophageal ulcers unless precautions are followed. The client must sit upright or stand for at least 30 minutes after taking the medication. The client should take the medication with a full glass of water, at least 30 minutes before eating or drinking anything or taking any other medication. Antacids will interfere with absorption and should not be taken at the same time. The nurse observes a new nurse administering a rectal suppository to a client. Which actions are appropriate for the new nurse to implement? (Select all that apply.) - Solution The nurse pushes the suppository in, up to the second knuckle. The nurse applies water-soluble lubricant to the suppository. The nurse places the client on the left side during insertion. After 10 minutes, the nurse turns the client to the right side. A nurse is caring for a client who was recently admitted following an episode of status epilepticus. Which of the following data is most important to collect? 1Level of consciousness (LOC) 2Amount of intravenous fluid infused 3Pulse and blood pressure 4Injuries to the extremities - Solution 1 The nurse is preparing a client for an intravenous pyelogram (IVP) test. What information is most important for the nurse to obtain prior to the procedure? 1Time of the client's last meal 2History of allergies 3Amount of urine output 4BUN and creatinine level - Solution 2 An older adult client, diagnosed with active pulmonary tuberculosis, has difficulty in coughing up secretions for a sputum specimen. Which nursing intervention would be most helpful for this client? 1Encourage client to ambulate frequently. 2Spray the oropharynx with saline. 3Administer a nebulizer treatment. 4Push fluids for the next eight hours. - Solution 3 It is important for the large intestine to be clear of stool to allow full visualization of the kidney, bladder and ureters. The nurse is preparing to suction a client's tracheostomy. What action should the nurse take to prevent hypoxia during the procedure? 1Explain procedure to client. 2Monitor heart rate during suctioning. 3Use sterile technique. 4Provide preoxygenation to the client. - Solution 4 The nurse is caring for a comatose client. To prevent keratitis, moisturizing ointment should be prescribed for which body site? 1Lower eyelids 2External ear canal 3Fingernails and toenails 4Perianal area - Solution 1 Unconscious or comatose clients are often unable to close their eyes or do not have a functioning blink reflex. When the eye remains open for a prolonged time, the cornea will dry out, causing irritation or ulceration. The nurse is in the process of inserting a urinary catheter in an adult female client. The nurse advances the catheter approximately 2 to 3 inches (5 to 7 cm), but no urine return is seen. What should the nurse do next? 1Inflate the catheter balloon. 2Advance the catheter a few more inches. 3Withdraw the catheter and try again. 4Notify the health care provider (HCP). - Solution 2 A child diagnosed with thalassemia has received several blood transfusions during the past three days. What lab value is the priority for the nurse to monitor with this client? 1Hemoglobin level 2Platelet count 3Blood urea nitrogen level 4Neutrophil percentage - Solution 1 A normal hemoglobin range for children is approximately 11 to 13 gm/dL. Thalassemia, also called Cooley's anemia, is a genetic defect that causes anemia, i.e., a condition in which the blood contains below-normal hemoglobin levels. Hemoglobin is the oxygen-carrying protein component of the red blood cell (RBC). The nurse initiates continuous enteral feeding at 8 am at 50 mL/hour for a client with malnutrition. It is now noon. What priority action should the nurse take at this time? 1Flush the feeding tube with 100 mL of water. 2Assess bowel sounds and gastric pH. 3Measure the gastric residual volume. 4Keep head of bed elevated at least 30 degrees. - Solution 3 A transesophageal echocardiogram (TEE) is ordered for a client with possible endocarditis. Which action included in the TEE orders should the nurse implement first? 1Place the client on NPO status. 2Administer O2 per nasal cannula. 3Start a peripheral IV line. 4Give midazolam (Versed) 1 mg IV push. - Solution 1 A pregnant woman in the third trimester is admitted with a report of painless vaginal bleeding that started several hours ago. The nurse should prepare the client for what procedure? 1Pelvic exam 2Abdominal ultrasound 3Nonstress test 4Caesarean section - Solution 2 A client has been taking isoniazid (INH) and rifampin for several months. Which laboratory test should the nurse monitor with this client? 1Creatinine clearance 2Cardiac enzymes 3Liver enzymes 4Sputum culture - Solution 3 INH and rifampin are used to treat tuberculosis and both are hepatotoxic. Isoniazid can cause hepatocellular injury A male client underwent a hernia repair in an outpatient surgery clinic. He is awake and alert, but has not been able to void since he returned from surgery six hours ago. He received 1000 mL of intravenous (IV) fluids. Which action should the nurse implement to help this client urinate? 1Have the client drink several glasses of water. 2Insert a urinary catheter. 3Assist the client to stand to void. 4Obtain a bladder ultrasound. - Solution 3 The nurse is caring for a client who had a closed reduction of a fractured right wrist, followed by the application of a cast about 12 hours ago. Which finding requires the nurse's immediate attention? 1Serum calcium level of 6.8 mg/dL 2Numbness in the right hand 3Reported pain level of six on a numeric pain scale 4Edema and swelling of the right hand - Solution 2 A nurse is caring for a client who had a cholecystectomy with common bile duct exploration and placement of a T-tube 24 hours ago. The nurse observes large amounts of bilious drainage from the T-tube. Which action should the nurse take? 1Administer pain medication. 2Clamp the T-tube for two hours. 3Continue to monitor the drainage. 4Lower the head of the bed. - Solution 3 A client is admitted to the hospital with endocarditis. The nurse understands that which risk factors can lead to the development of endocarditis? (Select all that apply.) - Solution Oral abscess with tooth extraction History of aortic valve replacement Placement of an arteriovenous fistula for hemodialysis Placement of a central venous access device The nurse is reviewing the chart of a client who was recently diagnosed with coronary artery disease due to atherosclerosis. Which factors most likely contributed to the development of this disease? (Select all that apply.) - Solution Mother died of a myocardial infarction Low-density lipoprotein (LDL) level of 149 mg/dL History of diabetes mellitus Used to smoke 40 packs per year until one year ago The target LDL level for a client is less than 100 mg/dL. The nurse is evaluating a client who was admitted for a small bowel obstruction and dehydration. Which observation by the nurse would indicate that the dehydration is improving? A client with a history of chronic alcohol use disorder is admitted to the inpatient unit with a serum magnesium level of 1.0 mEq/L. Which intervention should the nurse implement first? 1Assess the client's deep tendon reflexes. 2Order the client a meal with foods high in magnesium. 3Obtain the client's heart rate and oxygen saturation. 4Place the client on fall risk and seizure precautions. - Solution 3 The nurse administered furosemide to a client with acute pulmonary edema. Which observation by the nurse would indicate that the client is experiencing an adverse side effect of the medication? 1The client exhibits exertional dyspnea with walking. 2The client reports muscle cramps in both legs. 3The client's blood pressure is 104/60 mm Hg. 4The client's weight decreased by 2 lbs. in two days. - Solution 2 Muscle cramps and spasms while receiving diuretic therapy could indicate hypokalemia, an adverse drug effect of furosemide because this is a potassium wasting diuretic The nurse is reviewing the plan of care for a client with peripheral artery disease who has a history of leg pain with walking. Which interventions should the nurse include in the client's plan of care? (Select all that apply). - Solution Enroll the client in an exercise program that involves low-impact activities. Assist the client in selecting food items that are low in saturated fats and cholesterol. Reinforce teaching on the importance of not walking without shoes on. Assist the client in enrolling in a smoking cessation program. The nurse is caring for a client admitted with sickle cell crisis. Which medication is the drug of choice for pain management with this client? 1Meperidine 2Ibuprofen 3Acetaminophen 4Hydromorphone - Solution 4 The nurse is planning care for a client newly diagnosed with essential hypertension. Which interventions should the nurse include in the client's plan of care? (Select all that apply.) - Solution Encourage the client to take daily, 30-minute walks. Explain the negative effects of hypertension on Evaluate the client's understanding of a low-sodium diet. Evaluate the client's ability to take their own blood pressure. The nurse is assisting in developing a plan of care for a client who is on complete bedrest due to a spinal cord injury. Which intervention is most important for the nurse to include? 1Apply pneumatic compression devices to both legs. 2Turn and reposition the client every shift. 3Insert an indwelling urinary catheter. 4Administer a daily enema. - Solution 1 The nurse is reinforcing teaching for a client who was newly diagnosed with asthma. Clients with asthma should demonstrate understanding of which of the following? (Select all that apply.) - Solution Clients must understand the use of medications including quick-relief (rescue) and long-acting (maintenance) therapies. Clients use the peak flow meter to assess effectiveness of medication or breathing status. An acute attack can be a medical emergency and knowing where and how to seek medical care is important. Certain conditions (triggers) can exacerbate an attack and should be avoided. A client is seen at the primary care clinic for allergic rhinitis. Which clinical manifestations should the nurse expect with this diagnosis? (Select all that apply.) - Solution Common symptoms of allergic rhinitis are due primarily to the release of immune mediators such as histamine, prostaglandins, eosinophils and cytokines. This leads to sneezing, runny nose with clear discharge, nasal congestion and an increased eosinophil counts. Symptoms may appear similar to a cold. Due to drainage, the client's sense of smell can be altered. The nurse is caring for a client with a dry chest tube drainage system due to a left tension pneumothorax. Two hours ago, the health care provider (HCP) changed the chest tube prescription to water seal only. When entering the client's room, the nurse finds the client to be short of breath, tachypneic and with an oxygen saturation (SpO2) of 84%. On auscultation, the nurse notes absent breath sounds to the left upper lobe. What action should the nurse take first? 1Apply oxygen via nasal cannula 2Document all interventions in the client's medical record 3Notify the appropriate HCP 4Request a chest X-ray - Solution 1 The nurse is planning care for a client admitted to the hospital with influenza. Which interventions should the nurse include in the client's plan of care? (Select all that apply.) - Solution Antiviral agents, such as oseltamivir, are used to shorten the course and reduce symptoms of the flu. Droplet transmission-based precautions are indicated to prevent the spread of the flu. To avoid further transmission of the illness, visitors with signs/symptoms of a respiratory illness should not be permitted on the unit. It is important to ensure that clients understand how to prevent transmission of infections such as the flu through proper hand hygiene and cough etiquette. A client has been diagnosed with emphysema. Which intervention should the nurse implement when caring for this client? 1Inquire if the client has a power of attorney for health care. 2Reassure the client that the lung damage is usually reversible. 3Schedule a lung cancer screening for the client. 4Assist the client with enrolling in a smoking cessation program. - Solution 4 A nurse is administering the influenza vaccine in an occupational health clinic. Within 10 minutes of giving the vaccine to a middle-aged adult male, the man reports having itchy and watery eyes, feeling anxious and short of breath. What should the nurse do first? 1Administer SQ epinephrine. 2Maintain the airway. 3Take the client's vital signs. 4Apply oxygen. - Solution 1 4Nutritional deficits - Solution 1 The nurse is providing care to an 80-year-old client with the diagnosis of advanced Parkinson's disease. The nurse should know that the greatest risk to the client is related to which finding? 1Difficulties with reading and seeing at night 2Extreme weakness in the lower extremities 3Drooling and coughing when eating 4Dizziness and syncopal episodes - Solution 3 The home health nurse is reviewing the plan of care for a client experiencing acute attacks of Ménière's disease. What is the priority intervention for this client? 1Instruct the client not to drive a motor vehicle. 2Provide assistance with bathing and dressing. 3Communicate clearly and use visual aids. 4Encourage bland foods and noncarbonated fluids. - Solution 1 The nurse on the inpatient unit is expecting the admission of a client with a new onset of seizures and instructs the unlicensed assistive person (UAP) to prepare the client's room. Which piece of equipment should the UAP make sure to place in the room? 1Soft wrist restraints 2An oral airway 3A bedside commode 4Pads to be placed over the bed's side rails - Solution 4 The nurse is reinforcing discharge instructions for a client after cataract surgery of the left eye. Which statements by the client indicate an understanding of the instructions? (Select all that apply.) - Solution "I will follow the instructions for the eye drops." "I will call the surgeon if the pain is intense." "I will not rub, press on or scratch my eye." The nurse is providing care for a 40-year-old client suspected of having Guillain-Barré syndrome. Which intervention should the nurse plan for? 1Genetic testing of the client's children 2A bone marrow biopsy 3Administration of immunoglobulins 4Implementation of airborne precautions - Solution 3 Intravenous immunoglobulins (IV Ig) are used to treat Guillain-Barré in the early phase. They are believed to interfere with antigen presentation and help to modulate the body's immune response. The nurse in the neurology office is reviewing information about levetiracetam with a 30-year-old female client with a history of seizures. Which instruction about the medication should the nurse make sure to include? 1"You might experience irregular menses and intermittent bleeding." 2"Call the office immediately if you feel like hurting or killing yourself." 3"You should stay away from large crowds and sick children." 4"You should avoid becoming pregnant while taking this medication." - Solution 2 Levetiracetam is an anti-convulsant medication used to prevent seizures. One of the significant side effects is behavioral changes and suicidal ideations. The nurse is performing a home visit for an older adult client with Alzheimer's disease. Which of the following observations should be a priority for the nurse to address? 1Good lighting in the stairwell 2Throw rugs on the kitchen floor 3Lamps plugged directly into wall outlets 4Handrails in the bathtub - Solution 2 The nurse is collecting data from a college student who comes to the health clinic with symptoms of meningitis. The student resides in the school dormitory. What is the priority action the nurse should take? 1Perform a focused neurological assessment. 2Administer acetaminophen for the headache. 3Alert the college's administration and dormitory staff. 4Obtain the client's immunization history. - Solution 3 The clinic nurse is following up with a client who was seen a few days ago for trigeminal neuralgia. Which action by the client indicates an understanding of how to manage the condition? 1Takes an analgesic after performing household chores. 2Keeps the environment at a moderate temperature and free from drafts. 3Eats a bowl of hot, steaming soup every day for lunch. 4Performs vigorous brushing of teeth twice per day. - Solution 2 Trigeminal neuralgia is a disruption in the cranial nerve and causes sudden, severe, brief stabbing pain. Keeping the environment at a moderate temperature and free from drafts can reduce the risk of triggering an acute attack. The nurse in the long-term care facility is reviewing the plan of care for a client with Parkinson's disease. Which interventions should the nurse make sure to include for this client? (Select all that apply.) - Solution Set-up a bladder training program for the client. Encourage participation in speech therapy. Use cognitive strategies to enhance the client's memory. Provide assistance with ambulation. The nurse is reviewing the plan of care for a 30-year-old client newly diagnosed with multiple sclerosis. Which interventions should the nurse include for this client? (Select all that apply.) Instruct the client on how to self-catheterize as needed. Review methods to prevent and treat constipation. Encourage participation in physical and occupational therapy. Encourage participation in vocational rehabilitation. Encourage independence in personal care and bathing. - Solution Review methods to prevent and treat constipation. Encourage participation in physical and occupational therapy. Encourage participation in vocational rehabilitation. Encourage independence in personal care and bathing. "Make sure to drink the entire bowel preparation liquid." - Solution "You will have an intravenous catheter inserted prior to the procedure." "You should only consume clear liquids for the next 12 to 24 hours." "Remember to stop eating any food six hours before you come to the center." "Make sure to drink the entire bowel preparation liquid." A client is being admitted to the hospital with complaints of bloody stools for several days. Which interventions should the nurse expect to be prescribed for this client? (Select all that apply.) - Solution Administration of pantoprazole Collection of a stool sample for occult blood testing Discontinuation of all NSAID medications The nurse is reinforcing teaching with a client regarding their diagnosis of hepatic encephalopathy. Which statement by the client indicates that additional teaching is needed? 1"I will brush my teeth with a soft toothbrush to avoid bleeding gums." 2"I will eat enough protein and calories to stay healthy." 3"I will stop taking ibuprofen for my knee and back pain." 4"I will stop taking my lactulose when I have more than one loose stool." - Solution 4 The nurse is assisting with meal planning for a client with cholelithiasis. Which food items would be most appropriate for this client? (Select all that apply.) - Solution The most common cause of gallbladder disease is from stones that block the biliary ducts. Other causes are due to inflammation, infection, tumors or decreased blood flow due to damaged vessels. Intake of high cholesterol or fatty foods can increase the risk of gallbladder inflammation. To avoid inflammation, the client should follow a low cholesterol, low-fat diet and limit their intake of fried and processed foods such as breakfast cereals, lunch meats and microwavable meals. The nurse is assigned to care for a client with end-stage liver failure and portal hypertension. Which clinical manifestations would the nurse expect to see with these conditions? (Select all that apply.) Diminished pedal pulses Shortness of breath Increased weight gain Increased abdominal girth Elevated serum albumin level - Solution Shortness of breath Increased weight gain Increased abdominal girth Which discharge instruction should the nurse make sure to include for a client with chronic pancreatitis? 1"Make sure to eat a low-fat, high-fiber diet." 2"Try to reduce smoking cigarettes to half a pack per day." 3"Limit alcohol intake to one drink a day." 4"Take the prescribed pancreatic enzymes on an empty stomach." - Solution 1 The nurse is assisting in developing as plan of care for a postoperative client following a radical left mastectomy. Which nursing problem should be the priority for this client? 1Risk of infection of the surgical site 2Anxiety related to the cancer diagnosis 3Acute pain related to the surgery 4Impaired left arm circulation (lymphedema) - Solution 3 The nurse is evaluating a client's understanding of appropriate dietary choices with chronic kidney disease. Which food choices by the client indicate an understanding of the teaching? (Select all that apply.) Fresh apples Baked chicken Unsalted pretzels Slice of cheese Orange juice Baked potato - Solution Fresh apples Baked chicken Unsalted pretzels A client with chronic kidney disease (CKD) must limit intake of potassium, sodium, phosphorus and protein. In CKD, the kidneys are unable to adequately excrete these components. Foods low in potassium include: apples, grapes, lettuce and cauliflower. Foods high in potassium include: bananas, oranges, potatoes and spinach. Foods low in phosphorus include: chicken, shrimp, crab and rice. Foods high in phosphorus include: organ meats, salmon, scallops, nuts and cheese. A client comes to the community health clinic with symptoms of gonorrhea. Which intervention should the nurse implement first? 1Discuss the risk of infertility with the client. 2Collect a urethral swab from the client. 3Instruct the client to notify past sexual partners. 4Obtain information about the client's recent sexual encounters. - Solution 4 The nurse is assisting with developing a plan of care for a client with benign prostatic hyperplasia. Which nursing interventions should the nurse include for this client? (Select all that apply.) Limit caffeinated and alcoholic beverages. Calculate accurate intake and output. Void every 1 to 2 hours to empty the bladder. Catheterize as needed for post-void residual urine. Monitor for bladder distention. - Solution limit caffeine catheterize as needed monitor The nurse is reviewing the medical record of a client admitted with acute kidney injury. Which findings would support this diagnosis? (Select all that apply.) Proteinuria Hypokalemia Elevated creatinine level Decreased glomerular filtration rate Hematuria Decreased blood area nitrogen - Solution proteinuria elevated creatinine decreased function 4Review when the last dose of insulin was given. - Solution 1 The nurse in the primary health care provider's office is speaking with a 40- year-old male client whose most recent hemoglobin A1C level was 9%. The client states that he is motivated to make lifestyle changes to better manage his disease. What interventions should the nurse recommend for this client? (Select all that apply.) Eliminate all consumption of alcohol. Minimize intake of caffeinated beverages. Schedule an appointment with a registered dietitian. Start a weight loss program until BMI is below 25. Check the blood sugar several times a day, ideally before eating. Engage in regular physical activity, such as walking. - Solution Schedule an appointment with a registered dietitian. Start a weight loss program until BMI is below 25. Check the blood sugar several times a day, ideally before eating. Engage in regular physical activity, such as walking. The nurse is reinforcing education for a client with type 2 diabetes mellitus who is being discharged home. Which statement by the client would require clarification from the nurse? 1"At home, I should check my blood sugar before meals and at bedtime." 2"It is important to increase my physical activity gradually." 3"I will make sure to have an eye exam every five years." 4"When I administer my insulin, I will rotate injection sites." - Solution 3 Eye exams should be performed annually for diabetic clients due to the risk of diabetic retinopathy. The nurse is caring for a client who has suspected Cushing's disease. The nurse should monitor for which potential symptoms? (Select all that apply.) Large fat pads on the back and shoulders History of pathologic fractures Tachycardia and panic attacks Changes in visual acuity Polyuria and polydipsia - Solution Large fat pads on the back and shoulders History of pathologic fractures Cushing's disease occurs when there is an excess amount of cortisol. The nurse must understand that glucocorticoids, including cortisol, regulate NCSBN NCLEX (QUESTIONS WITH 100 % CORRECT SOLUTIONS 2024 UPDATED GRADED A+) A LPN complains to the charge nurse that an unlicensed assistive person (UAP) consistently leaves the work area untidy and does not restock supplies. What is the best initial response by the charge nurse? 1Write down potential solutions to the problems today by shift's end 2Add this concern to the agenda of the next unit meeting 3Assure the staff nurse that the complaint will be investigated 4Explore for further identification about the nature of the problem - Solution 4 Explore for further identification about the nature of the problem The nurse assists with the reinforcement of information about breast self- examination to a group of college students. A female student asks when to perform the monthly exam. The appropriate reply by the nurse should include which statement? 1"Ovulation, or midcycle is the best time to detect changes." 2"Do the exam at the same time every month." 3"Right after the period, when your breasts are less tender." 4"The first of every month, because it will be easiest to remember." - Solution 3 The nurse is caring for a 75 year-old client with type 2 diabetes mellitus. The client should be instructed to contact the outpatient clinic immediately if which findings are present? 1An open wound on the heel with minimal discomfort 2Occasional hiccups and sneezing 3Sustained insomnia and daytime fatigue 4Persistent dryness and itching of the perineal area - Solution 1An open wound on the heel with minimal discomfort- A pregnant woman has been advised to alter her diet during pregnancy by increasing the intake of protein and vitamin C to meet the needs of the growing fetus. Which diet choice would best meet the woman's needs? 1. 1 cup of macaroni, three-fourths cup of peas, glass whole milk, medium pear 2. Scrambled egg, hash browned potatoes, one-half glass of buttermilk, large nectarine 3. 3 oz. chicken, one-half cup of corn, lettuce salad, small banana 4. Beef, one-half cup of lima beans, glass of skim milk, three-fourths cup of strawberries - Solution 4. Beef, one-half cup of lima beans, glass of skim milk, three-fourths cup of strawberries - A nurse is taking a health history from parents of a child admitted with possible Reye's syndrome. Which recent illness should the nurse recognize as being associated with an increased the risk for the development of Reye's syndrome? 1. Varicella 2. Meningitis 3. Hepatitis 4. Rubeola - Solution 1. Varicella - A Native American chief visits his newborn son and performs a traditional ceremony that involves feathers and chanting. The nurse comments to a colleague: "I wonder if he has any idea how ridiculous he looks - he's a grown man!" The nurse's comment is an example of what type of attitude? 1. Prejudice 2. Ethnocentrism 3. Discrimination 4. Stereotyping - Solution 1. Prejudice- A nursing student asks the licensed practical nurse (LPN) to explain the forces that drive health care reform. When responding to the student's question, what information should the nurse emphasize? 1. Increased competition between health care insurers 2. Increase in health care spending that's growing faster than the economy 3. Increase in the population who have health insurance 4. Increase in spending for end-of-life treatment - Solution 2 A child is admitted to the unit with the suspected diagnosis of pertussis (whooping cough). What is the priority nursing intervention for this child? 1. Maintain hydration and encourage fluids 2. Implement droplet precautions 3. Monitor respiratory rate and oxygen saturation 4. Anti- infective therapy - Solution 2 A client has an indwelling catheter with continuous bladder irrigation after undergoing a transurethral resection of the prostate (TURP) 12 hours ago. The LPN is unsure about an assignment by the charge nurse to hang an intravenous (IV) infusion that contains potassium. What resource should the LPN check first to determine if LPNs can administer IV medications? 1Employer policy and procedures manuals 2Nursing faculty from a local nursing program 3The nurse practice act of the state in which the practice takes place 4American Nurses Association (ANA) professional standards - Solution 3 The nurse is assisting with the delivery of a newborn infant. What is the priority nursing intervention for a normal newborn immediately after delivery? 1Dry off infant with a warm blanket or towel 2Apply identification bracelets 3Assign the one-minute APGAR score 4Obtain vital signs - Solution 1Dry off infant with a warm blanket or towel - The registered nurse is teaching a childbirth education class about postpartum depression. Which statement, made by a class member, indicates that more teaching is needed? 1"I will make an effort to talk with someone about my feelings if I start to feel overwhelmed." 2"It's common for women with postpartum depression to have delusions about the infant." 3"Women with postpartum depression have feelings of guilt and worthlessness." 4"I may experience postpartum depression up to a year after delivery." - Solution 2 The nurse is reinforcing information about the side effects of fluoxetine to a client. Which group of findings should be included? 1Diarrhea, dry mouth, weight loss, reduced libido 2Tachycardia, blurred vision, hypotension, anorexia 3Orthostatic hypotension, vertigo, reactions to tyramine, nausea 4Photosensitivity, seizures, edema, hyperglycemia - Solution 1Diarrhea, dry mouth, weight loss, reduced libido A client has a diagnosis of heart failure. Which intervention is most important for the nurse to implement prior to the administration of digoxin? 1Use the pulse reading from the electronic blood pressure device 2Take a radial pulse, counting for a full 60 seconds 3Check for a pulse deficit at least twice with another nurse 4Assess the apical pulse, counting for a full 60 seconds - Solution 4Assess the apical pulse, counting for a full 60 seconds - A client diagnosed with bipolar disorder refuses to take the prescribed medication. Which is the most therapeutic response by a nurse to the client's refusal of the medication? 1"You need to take your medicine. This is how you get better." 2"What is it about the medicine that you don't like?" 3"I can see that you are uncomfortable right now; let's talk about it tomorrow." 4"If you refuse your medicine, tell me how do you think you will get better?" - Solution 2 A parent expresses frustration and anger about the toddler constantly saying "no" and refusing to follow directions. The nurse should help the parent understand that this behavior meets which developmental need? 1Self-esteem 2Initiative 3Independence 4Trust - Solution 3 The LPN is assisting the RN to provide care for a client diagnosed with a traumatic brain injury. Using the Glasgow Coma Scale, when the client does not obey verbal commands to move, which technique will the RN use to evaluate motor function? 1Squeeze the trapezius muscle firmly 2Lift the client's arm and observe for pronation and drift 3Apply finger tip pressure for 10 seconds 4Rub the sternum with the knuckles - Solution 1Squeeze the trapezius muscle firmly - A newborn has hyperbilirubinemia and is being treated with a biliblanket. Which intervention is indicated during this therapy? 1Discontinue breastfeeding during treatment 2Rotate the neonate to treat all of his/her skin 3Restrict holding the newborn during treatment 4Provide more frequent feedings - Solution 4Provide more frequent feedings- A client with paranoid delusions stares at the nurse over a period of several days. The client suddenly walks up to the nurse and shouts, "You think you're so perfect, pure and good." How should the nurse respond? 1"You seem to be in a bad mood." 2"Perfect? I don't quite understand." 3"You sound angry right now." 4"That explains why you've been staring at me." - Solution 3 The client with coronary artery disease has a prescription for nitroglycerin transdermal patches. What is the best reason the client should not wear a patch for more than 12 to 14 hours each day? 1It can cause severe headaches 2It may no longer work as well 3It will cause profound hypotensive effects 4it will irritate the skin - Solution 2 A hospitalized infant is receiving gentamicin. Which nursing intervention should receive priority in the plan of care? 1Compare daily infant weights 2Monitor the infant's urine output 3Ensure appropriate fluid intake 4Maintain accurate intake and output - Solution 2 A newborn is diagnosed with hypothyroidism. In discussing the condition and treatment with the family, the nurse should emphasize which point? 1They can expect the child will be mentally retarded 2Administration of a thyroid hormone will prevent problems 3This rare condition is hereditary 4Physical growth and development will be delayed - Solution 2 A child is admitted to the hospital for emergency surgery. The child's parent reports several allergies. Which of these allergies should all the operative health care personnel be notified about? 1Perfumed soap 2Shellfish 3Balloons 4Mold - Solution 3 A practical nurse (PN) team member identifies that the fundus is boggy for a woman who is gravida 4 para 4 and is two hours after a spontaneous 3Discuss the diet with the client to learn the reasons for not following the diet - 4Recommend a release from home health care related to noncompliance - Solution 3 A client has chronic renal failure and is being treated at home. During weekly home visits, which factor is the most accurate indicator of fluid balance? 1Trends in daily weights - 2Skin turgor over at least two areas of the body 3Changes in mucous membrane moistness 4Difference between intake and output - Solution 1Trends in daily weights - The client is receiving a thrombolytic agent to open a clot-occluded coronary artery following a myocardial infarction. Which finding would be the greatest concern and should be immediately reported to the registered nurse? 1Hematemesis - 2Pink-tinged saliva 3Serosanguinous drainage from the IV site 4Slight rust-colored urine - Solution 1Hematemesis - The nurse is caring for a postoperative client following a closed reduction of distal tibia and mid-femur fractures. The client has a long leg plaster cast. Thirty-six hours after surgery, the client suddenly becomes confused, short of breath and spikes a temperature of 103 F (39.4 C). What should be the first action by the nurse? 1Check the distal circulation of the casted extremity 2Obtain the pulse oximetry reading 3Measure the client's blood pressure in the supine and Fowler's positions 4Check the orientation to time, place and person - Solution 2 The client has an order for intermittent gastrostomy tube (G-tube) feedings. What is the priority action by the nurse to accurately assess correct placement of the G-tube? 1Listen for active bowel sounds in all four quadrants 2Measure the pH of stomach content aspirate 3Auscultate the abdomen while instilling 10 mL of air into the G-tube 4Measure the length of tubing from the insertion site each shift - Solution 1Listen for active bowel sounds in all four quadrants 2Measure the pH of stomach content aspirate - 3Auscultate the abdomen while instilling 10 mL of air int1Listen for active bowel sounds in all four quadrants 2Measure the pH of stomach content aspirate - 3Auscultate the abdomen while instilling 10 mL of air into the G-tube 4Measure the length of tubing from the insertion site each shifto the G-tube 4Measure the length of tubing from the insertion site each shift The client is diagnosed with infective endocarditis of the tricuspid valve. Which finding suggests a complication of this condition? 1Pronounced wheezes 2Pain on deep inspiration 3Sudden back pain 4Sudden dyspnea - Solution 4 A client is scheduled for a percutaneous transluminal coronary angioplasty (PTCA). What should the nurse understand about the purpose of this procedure? 1The surgical repair of a diseased coronary artery 2An noninvasive radiographic examination of the heart 3A process to compress arterial plaque to improve blood flow 4The placement of an automatic internal cardiac defibrillator - Solution 3 A 2 day-old infant born with spina bifida and meningomyocele is recovering after an initial surgery. As the nurse accompanies the grandparents for their first visit since the child's birth, which of these responses might the nurse expect from the grandparents? 1Anger 2Disbelief 3Depression 4Frustration - Solution 2 The ICU nurse works in a rural hospital that has a remote electronic ICU monitoring system (eICU.) What is one of the best reasons for having access to an eICU? 1An ICU nurse and intensivist remotely monitor ICU clients around the clock 2An ICU nurse is on-call to solution questions when needed 3Clients can ask the intensivist for a second opinion 4Less staff is needed on site when a remote eICU is available - Solution 1 A child has severe burns to the lower extremities. A diet high in protein and carbohydrates is recommended. The nurse should care for this client with the knowledge that the most important reason for such a diet is to achieve which result? 1Provide a well-balanced nutritional intake 2Promote healing and strengthen the immune system 3Spare protein catabolism to meet metabolic and healing needs 4 stimulate increased peristalsis and nutrient absorption - Solution 3 A nurse is reinforcing information about the administration of an albuterol inhaler to an adult diagnosed with asthma. What should be the priority comment made by the nurse? 1"Use this medication at bedtime to promote rest." 2"Notify the health care provider if your canister lasts only two weeks." 3"Inhale this medication after other asthma sprays." 4"Discontinue the inhaler if you are dizzy." - Solution 2 An 80 year-old client is hospitalized for a chronic condition. The client informs family members that a living will has been prepared and the client wants no life-prolonging measures performed. The client's condition deteriorates and the client becomes unresponsive. Which of the following nursing actions is most appropriate? 1Notify the attending physician 2Consult the charge nurse and prepare to transfer the client to an intensive care unit 3Call the rapid response team 4Contact the family member indicated in the admission forms - Solution 1 The nurse is caring for a client who has just been admitted to the inpatient mental health unit with severe depression. Which concern should be a priority of care? 1Safety 2Elimination 3Rest 4Nutrition - Solution 1 A client is scheduled to have blood drawn for serum cholesterol and triglycerides tomorrow morning. What information should the nurse reinforce to the client about the test? 1"Be sure to eat a fat-free diet until the test, and drink lots of water." 2"Stay at the laboratory so that two blood samples can be drawn an hour apart." 3"Do not eat or drink anything but water for 12 hours before the blood test." 4"Have the blood drawn within two hours of eating breakfast." - Solution 3 The nurse is caring for a hospitalized adolescent. The nurse recognizes that which of these concerns will be the greatest for a hospitalized adolescent? 1Restricted physical activity 2Separation from family 3Altered body image 4Unrelieved pain - Solution 3 In checking a postpartum client, the nurse palpates a firm fundus. However, the nurse also observes a constant trickle of bright red blood from the vaginal opening. What should the nurse suspect? 1Retained placenta 2Clotting disorder 3Vaginal lacerations 4Uterine atony - Solution 3 A client diagnosed with gout is admitted with severe pain, swelling and redness in the proximal toe joint of the right foot. The nurse should anticipate that the plan of care would include which focus? 1High-protein diet 2Fluid intake of at least 3000 mL/day 3Acetaminophen for inflammation 4Hot compresses to affected joints - Solution 2 A 6 year-old child is hospitalized with findings of moderate edema, gross hematuria and mild hypertension associated with the diagnosis of acute glomerulonephritis (AGN). Which nursing intervention would be appropriate for this client? 1Weigh the child twice per shift 2Relieve boredom through physical activity 3Institute seizure precautions 4Encourage the child to eat protein-rich foods - Solution 3 A mother asks about expected motor skills for her 3 year-old child. Which activity should the nurse discuss as normal at this age? 1Riding a tricycle 2Tying shoelaces 3Jumping rope 4Playing hopscotch - Solution 1 The nurse is assessing a client who has been treated long-term with glucocorticoid therapy. Which finding might the nurse expect? 1Jaundice 2Peripheral edema 3Buffalo hump 4Increased muscle mass - Solution 3 A client diagnosed with autism begins to eat with both hands. The nurse can best handle the behavior by using which approach? 1Commenting "I believe you know better than to eat with your hands." 2Removing the food and stating "You can't have any more food until you use the spoon." 3Jokingly stating "Well, I guess fingers sometimes work better than spoons." 4Placing the spoon in the client's hand and stating "Use the spoon to eat your food." - Solution 4 The client is diagnosed with heart failure and oral digoxin is prescribed. What is the priority nursing assessment for this medication? 1Monitor serum electrolytes and creatinine 2Measure apical pulse prior to administration 3Maintain accurate intake and output ratios 4Monitor blood pressure every 4 hours - Solution 2 A 16 month-old child has just been admitted to the hospital. As the nurse assigned to this child enters the hospital room for the first time, the toddler runs to the mother, clings to her and begins to cry. What should be the next action of the nurse? 1Arrange to change client-care assignments 2Discuss with the parent the appropriate use of "time-out" 3Explain to the mother that the child needs extra attention 4Explain to the parent that this behavior is expected - Solution 4 The mother of a hospitalized 2 year-old child asks a nurse's advice about the child's screaming every time the mother gets ready to leave the hospital room. The best advice by the nurse would include which approach? 1Explain that this behavior will stop with in a few days 2Suggest that the mother "sneak out" of the child's room when the child is asleep 3Request for the mother to remain with the child at all times 4Help the mother understand that this is a normal response to hospitalization - Solution 4 A client has a percutaneous endoscopic gastrostomy (PEG) tube that is used to administer feedings and medications. Which nursing action is best to ensure patency of the tube? 1Encouraging the client to cough to relieve abdominal bloating prior to or following a feeding 2Adequately flushing the tube with water before and after use 3Completely crushing all medications prior to administration 4Squeezing the tube to dislodge obstructions - Solution 2 A nurse is observing an 8 month-old client. Which behavior would the nurse anticipate the infant to be able to display? 1Pull up to stand 2Use a spoon 3Say two words 4Sit without support - Solution 4 A client is admitted with newly diagnosed hypothyroidism. A nurse would expect the client to exhibit which finding until the client achieves a euthyroid state with therapy? 1Heat intolerance 2Diarrhea 3Tachycardia 4Lethargy - Solution 4 The licensed practical nurse is caring for a client with advanced cirrhosis of the liver. Which finding should receive immediate follow-up by the charge nurse? 1Jaundice 2Respiratory function 3Bladder control 4Peripheral sensation - Solution 2 There's a new order to apply one-inch of nitroglycerin paste to the client's chest every 12 hours, but the medication is not in the automatic medication dispensing system's drawer for this client. What should the nurse do next? 1Use another client's nitroglycerin paste until pharmacy sends a tube for this client 2Substitute an equivalent amount of nitroglycerin sublingual spray from the crash cart 3Call the pharmacy to send up a tube of nitroglycerin paste 4Call the prescriber and ask to substitute a different formulation of nitroglycerin - Solution 3 A nurse is caring for a child being discharged after a tonsillectomy. Which instruction is appropriate for the nurse to reinforce with the parents? 1Report a persistent cough to the health care provider 2The child can return to school in four days 3Administer chewable medication for pain 4The child may gargle as necessary for discomfort - Solution 1 An 80 year-old client is scheduled for a cardioversion. The nurse is reviewing the client's medication administration records for the previous 24 hours. Which medication would prompt the nurse to notify the health care provider? 1Diltiazem (Cardizem) 2Digoxin (Lanoxin) 3Nitroglycerine ointment 4Metoprolol tartrate (Toprol XL) - Solution 2 A nurse has reinforced teaching for a client who is being discharged after an arterial revascularization of the right lower extremity. Which statement made by the client is incorrect and requires further discussion with the nurse? 1"Smoking will decrease the circulation to my leg" 2"Coughing and deep breathing are important for a few weeks." 3"I will put my right leg through a full range of motion." 4"I might feel a throbbing pain in my right leg." - Solution 3 The nurse is assisting in the application of a plaster cast for a client with a broken arm. Which action is a priority? 1The cast material should be dipped several times into warm water 2The cast should be uncovered until it dries 3The casted extremity should be placed on a supporting surface 4The wet cast should be handled with the palms of hands for 48 to 72 hours - Solution 4 The client undergoes a gastrectomy. Several hours after surgery, the nasogastric (NG) tube stops draining. What action does the LPN anticipate the RN will take first? 1Reposition the tube 2Increase the amount of suction 3Gently irrigate the tube with sterile normal saline 4Notify the surgeon - Solution 3 A 12 year-old child, admitted with a broken arm, is waiting for a scheduled surgery. The nurse finds the child crying and unwilling to talk. What would be the most appropriate initial response by the nurse? 1Reassure the child that the surgery will go fine with no problems 2Provide privacy with encouragement to work through feelings 3Distract the child with a choice of activities to do while waiting for surgery 4Make arrangements for friends to visit as soon as possible - Solution 2 A nurse is caring for a client with a sigmoid colostomy. The client requests assistance in removing the flatus from a one-piece drainable ostomy pouch. Which intervention should the nurse use? 1Pierce the plastic at the top of the ostomy pouch with a pin to vent the flatus 2Pull the adhesive seal around the ostomy pouch to allow the flatus to escape 3Open the bottom of the pouch to allow the flatus to be expelled 4Assist the client to ambulate to reduce the flatus in the pouch - Solution 3 A client returns from the operating room after a right orchiectomy. What is the priority nursing intervention during the immediate postoperative period? 1Manage postoperative pain 2Maintain fluid and electrolyte balance 3Control bladder spasms with PRN medication 4Ambulate the client within a few hours after surgery - Solution 1 The nurse enters the room of a postpartum mother and observes the baby lying at the edge of the bed while the mother sits in a chair. The mother states, "This is not my baby, and I do not want it." How should the nurse respond? 1"What a beautiful baby! The baby's eyes are just like yours." 2"This is a common occurrence after birth. Let's talk about how to accept the baby." 3"You seem upset, tell me about how you are feeling"? 4"Many women have postpartum blues and need some time to love the baby." - Solution 3 The client calls the clinic nurse and reports nausea, headache and fatigue. The client also reports seeing yellow halos around lights. What is the best response by the nurse? 1"Do your eyes appear bloodshot and is there any itching?" 2"Tell me about your prescription for digoxin. Are you still taking the medication?" 3"Call back in a week and schedule an appointment if your symptoms don't improve." 4"Is there anyone else at home who has the same symptoms?" - Solution 2 A client is admitted to the mental health inpatient unit with a diagnosis of major depression after a suicide attempt. In addition to expressions of sadness and hopelessness, the nurse anticipates observing which characteristics? 1Meticulous attention to hygiene, grooming 2Anxiety, hostility 3Psychomotor retardation, agitation 4Guilt, indecisiveness - Solution 3 A nurse is assigned to care for a 10 month-old infant with the new diagnosis of anemia. Which of these findings should the nurse anticipate? 1Behavior consistent with hyperactivity 2Slow heart rate when sleeping 3Pale mucosa inside the mouth 4High hemoglobin level - Solution 3 A client becomes acutely short of breath with an SpO2 (oxygen saturation) of 82%. Which oxygen delivery system should the nurse apply that would provide the highest concentrations of oxygen to the client? 1Simple face mask 2Partial rebreather mask 3Venturi mask 4Non-rebreather mask - Solution 4 A nurse gathers data related to delayed gross motor development in a 3 year-old client. Which observation by the nurse should confirm this finding? 1Cannot ride a bicycle 2Cannot catch a ball 3Cannot skip on alternate feet 4Cannot stand on one foot - Solution 4 A client is admitted to the hospital with a history of confusion. The client has difficulty remembering recent events and becomes lost when outside of the home. Which statement would provide the best reality orientation for this client? 1"Hello. My name is Elaine Jones and I am your nurse for today." 2"Good morning. You're in the hospital. I am your nurse Elaine Jones." 3"How are you today? Remember, you're in the hospital. I will be your nurse all day. My name is Elaine Jones." 4"Good morning. I am Elaine Jones, your nurse. Do you remember where you are?" - Solution 2 A client is diagnosed with a Salmonella infection. What is a primary nursing intervention to be taken to minimize the transmission of disease from this client? 1Double glove when in contact with feces or emesis 2Wash hands thoroughly before and after any client contact 3Wear gloves when disposing of contaminated linens 4Use gloves when in contact with body secretions - Solution 2 A 6 month-old infant is being treated for developmental hip dysplasia and has been placed in a hip spica plaster cast. Which discharge information is important for the nurse to reinforce with the parents? 1Turn the baby every two hours using the abduction stabilizer bar 2Check frequently for swelling in the baby's feet 3Gently rub the skin with a cotton swab to relieve itching 4Place favorite books and push-pull toys in the crib - Solution 2 A nurse is talking to parents about the side effects of routine immunizations. Which finding should the nurse reinforce about calling the health care provider if it occurs within 24 to 48 hours after a routine immunization? 1Localized tenderness at the injection site 2Tympanic temperature of 104 F (40 C) 3Some irritability and fussiness 4Swelling at the injection site - Solution 2 A 28-year-old is transferred to the emergency department (ED) via ambulance with a traumatic head injury. The client is awake and reports having a headache and some amnesia. What are the priority nursing interventions for this client? (Select all that apply.) - Solution Correct Response Assess vital signs and neurological function Assess the airway Prepare for CT imaging of the head Assess the wound for presence of drainage or bruising on the head A client exhibits many delusional thoughts. As the nurse assists the client to prepare for breakfast, the client comments, "Don't waste good food on me. I'm dying from this disease I have." Which response by the nurse would be the best? 1"None of the laboratory reports show that you have any physical disease." 2"Try to eat a little bit. Breakfast is the most important meal of the day." 3"I know you believe that you have an incurable disease." 4"What has your primary health care provider told you?" - Solution 3 The family member tells an admitting nurse that the client values the practice of Chinese medicine. The nurse must understand that for this family and client a priority goal should take which focus? 1Achieve harmony 2Respect life in old age 3Maintain energy balance 4Restore yin and yang - Solution 4 The nurse is reinforcing dietary instructions to the parents of a child diagnosed with cystic fibrosis. The nurse will emphasize which of the following characteristics of this diet? 1A gluten-free diet, avoiding foods that contain wheat, rye and barley 2Balanced, high calorie diet with extra fat, salt, protein and calcium 3Foods low in sodium, potassium and phosphorus 4Carbohydrate counting, selecting foods from the bread/starch, fruit, or milk group - Solution 2 The nurse works in a psychiatric inpatient setting. What information should the nurse be aware of as one of the most frequent reasons for suicide in adolescents? 1Progressive failure to adapt to peer pressure 2Reunion wish or a fantasy of some sort 3Feelings of anger or hostility toward others 4Feelings of alienation or isolation from peers - Solution 4 When a client returns from surgery after an open reduction with cast application for a femur fracture, a small blood stain is noted on the cast by the nurse. Four hours later, the nurse observes that the stain has doubled in size. What is the initial action for the nurse to take at this time? 1Ask the family members to call you when they notice the spot getting larger 2Record the findings in the nurse's notes 3Outline the spot with a pen and note the time and date on the cast 4Report the finding to the registered nurse (RN) charge nurse - Solution 3 The nurse is discussing an illness with a 10 year-old child. What should the nurse keep in mind about this child's ability to understand the information at this stage of development? 1Makes simple association of ideas 2Bases conclusions on abstract thinking I3nterprets events from own perspective 4Thinks logically to organize facts - Solution 4 The nurse calls for help after finding an unresponsive adult client in a hospital room. What action should the nurse take next for the client who has no pulse and is not breathing? 1Open the airway and deliver two breaths followed by 30 compressions The client is seen in the emergency one day after falling in his bathroom at home. The client reports having "a few drinks" prior to the fall. Which finding requires the nurse's immediate attention? 1Bruise behind one ear 2Blurred vision 3Nausea and vomiting 4Headache - Solution 1 Diagnosed with heart failure, the client had an implantable cardioverter- defibrillator (ICD) implanted several years ago. The client now has end- stage heart failure and is receiving home hospice care. Which end-of-life care option could have the greatest impact on client comfort? 1Encouraging the client to sit upright in bed 2Confirming advanced directives and plans for resuscitation 3Deactivating the implantable cardioverter-defibrillator (ICD) 4Assisting the client to eat several small meals - Solution 3 The client is prescribed alendronate (Fosamax). What information about medication administration should the nurse be sure to reinforce? 1Take on an empty stomach 2Take with milk, two hours after meals 3Take with calcium 4Take after meals - Solution 1 A couple experienced a miscarriage at seven months of pregnancy. The nurse makes a home visit one week after discharge from the hospital. What intervention should the nurse emphasize to the couple during the home visit? 1Plan another pregnancy as soon as possible 2Seek causes of the death for prevention purposes 3Focus on the other healthy children at home 4Discuss feelings with support persons and each other - Solution 4 A nurse is reinforcing information to a mother who is breast-feeding a newborn infant diagnosed with oral candidiasis. Which statement by the mother would be incorrect and indicate a need for reinforcement of information? 1"The therapy can be discontinued when the spots disappear." 2"I will boil the nipples and pacifiers for 20 minutes." 3"Expressed breast milk should be used immediately or frozen." 4"Nystatin should be given four times a day after my baby eats." - Solution 1 The nurse is to administer meperidine 100 mg, atropine 0.4 mg, and promethazine 50 mg IM to a client preoperatively. Which action should the nurse take initially? 1Place the bed in the low position 2Instruct the client to remain in bed 3Place the call bell within reach 4Have the client empty the bladder - Solution 4 The parents of a school-age child are providing information to the nurse about their child. Which of these health issues should the nurse recognize as a finding that could suggest type 1 diabetes? 1Being a picky eater 2Weight gain 3Bedwetting 4Oily and acne-prone skin - Solution 3 An adolescent client arrives at a clinic three weeks after the birth of her first baby. She tells the nurse she is very worried about not returning to her pre- pregnancy weight. Which approach should the nurse take first? 1Review the client's pattern of weight gain over the past year 2Encourage her to talk about her self-image 3Give her several pamphlets on postpartum nutrition 4Ask the mother to record her diet for the next few weeks - Solution 2 A nurse is caring for a client admitted with the diagnosis of suspected Legionnaire's disease. Which finding would require the nurse's immediate attention? 1Dry mouth with frequent requests for water 2Abdominal gas pains that are severe and disappear suddenly 3 Increased use of accessory muscles of breathing 4Difficulty sleeping due to leg cramps - Solution 3 Legionnaire's disease is a type of acute bacterial pneumonia. Increased use of accessory breathing muscles and labored breathing are indicators of respiratory distress and should be reported immediately. The nurse is caring for a client with congestive heart failure. Which task can the nurse delegate to the unlicensed assistive person (UAP)? 1Record and report the client's intake and output. 2Inspect and report peripheral IV site status. 3Palpate for edema in the lower extremities. 4Evaluate understanding of prescribed medications. - Solution 1 A client refuses to take the medication prescribed because the client prefers to take an herbal preparation instead. What is the first action the nurse should take? 1Discuss with the client to find out about the preferred herbal preparation 2Explain the importance of the medication to the client 3Contact the client's health care provider about the refusal 4Report the behavior to the charge nurse - Solution 1 The nurse is caring for a group of clients when a fire alarm sounds in the hospital cafeteria. What should the nurse do next? 1Close all doors in the area. 2Find the fire extinguisher. 3Remove oxygen devices. 4Begin evacuating the clients. - Solution 1 The licensed practical nurse (LPN) is caring for a client with an order that reads, "morphine sulfate 2 mg IV push every 3 to 4 hours as needed for pain." There are no other licensed persons working that shift. Which action should the nurse take? 1Give the medication orally and follow-up with the health care provider. 2Hold the medication and contact the health care provider. 3Administer the prescribed dose as ordered. 4Check with the pharmacist to verify the order. - Solution 2 The nurse is providing care for a client who was recently diagnosed with end-stage heart failure. The client does not have advance directives in place. Which of the following statements by the nurse would be appropriate? (Select all that apply.) - Solution "Have you thought about what you want done as your disease progresses?" "What does your family know about your condition and prognosis?" "Have you discussed your wishes regarding resuscitation with your health care provider?" A client with a musculoskeletal disorder has been newly fitted with a lower limb orthotic. Which activity can the nurse delegate to the certified nursing assistant (CNA)? 1Provide instruction to the client for ambulation with the orthotic. 2Monitor the client's response to moving with the orthotic. 3Check the client's skin for any redness or irritation from the orthotic. 4Assist with transferring the client from the bed to the chair. - Solution 4 Upon completing a review of a 27-year-old client's admission documents, the nurse identifies that the client does not have an advance directives. What action should the nurse take? 1Lecture the client on the importance of having advance directives. 2Inform the charge nurse to offer information about advance directives. 3Advance directives are not appropriate for this client due to the client's age. 4Refer this issue to the client's health care provider. - Solution 2 The home health nurse is visiting a client diagnosed with type 1 diabetes and osteoarthritis. The client has difficulty holding and using the prescribed insulin pen. The nurse should refer the client to which community resource person? 1Physical therapist 2Pharmacist 3Physical therapist 4Occupational therapist - Solution 4 Holding and using an insulin pen requires fine motor skills and good vision. A client with osteoarthritis (OA) might experience limited movement and pain in the joints of the fingers and hand. An occupational therapist can help a client improve the fine motor skills needed to prepare an insulin injection. An occupational therapist works with clients to perform tasks that are needed for smaller movements to maintain activities of daily living or for work. A client diagnosed with schizophrenia insists that the nurse explain the use and side effects of the medications prescribed for the client. What should the nurse understand before responding to the client? 1The psychiatrist will need to grant permission to discuss the client's medications. 2All clients have a right to be informed about their prescribed medications 3A decision to reinforce or not reinforce information about medications should be made by the nurse alone. 4It is too dangerous for clients who are diagnosed with schizophrenia to know about their medications. - Solution 2 The nurse asks another staff nurse to sign for wasting a partial-dose opioid injection, although the wasting was not witnessed by anyone. This type of request seems to be a pattern of behavior for this nurse. What is the most appropriate action for the second staff nurse to take? 1Report this request immediately to the nurse manager. 2Review the client's medication administration record (MAR) for past wastes. 3Ask the nurse's client if they witnessed the waste of the partial dose. 4Confront the nurse about suspected narcotics diversion. - Solution 1 A client diagnosed with bipolar disorder has been referred to social services for possible placement in a community halfway house after discharge. The social worker telephones the nurse and asks for information about the client's mental status and adjustment. What should the nurse do next to respond to this request? 1Go ahead and provide the information, since the client is ready for discharge. 2Inform the caller that this kind of information is never given over the telephone. 3Refer the social worker to the health care provider to obtain the requested information. 4Verify that the client's medical record includes the client's written consent to release information. - Solution 4 During a discussion about a living will, the client's son states, "I do not understand the need for a living will." What is the best response by the nurse? 1"Health care decisions can be made based on the client's wishes." 2"Specific instructions are listed for specific diseases." 3"A designated family member can make all decisions." 4"Do not resuscitate (DNR) orders are automatic under these conditions." - Solution 1 The client requests not to be interrupted before 10 am because it interferes with the client's time to meditate. What action shall the nurse take first? 1Document the client's request in the medical record. 2Meet with the client to formulate a mutually agreeable schedule. 3Notify the dietary department about the client's request. 4Adjust administration times for prescribed medications. - Solution 2 A client who recently experienced a stroke has an order to ambulate with assistance. Which statement by the nurse provides the best instructions to the unlicensed assistive person (UAP) who will assist the client to ambulate? 1"Have the client lift and move the walker out to arm's length, then walk into the walker." 2"If the client becomes dizzy while walking, ask the client to stop and take 10 fast, deep breaths." 3"As you assist the client to the chair, let me know if the client uses the quad cane correctly." 4"Stand on the client's strong side when you assist the client to the bathroom." - Solution 1 The person assisting the client to ambulate should walk on the client's weak side, NOT STRONG, side. The nurse is reviewing information about the health care organization's efforts to improve quality of care. Which of these statements best describes the goal of continuous quality improvement (CQI) in a health care setting? 1Perform actions based on reactive problem solving. 2Create a flow chart of department or staff interactions. 3Conduct chart audits for common error discovery. 4Improve the quality of care in a proactive manner. - Solution 4 The client is admitted with a diagnosis of hyperglycemia and poor glycemic control. Which task can the nurse assign to an unlicensed assistive person (UAP)? 1Check sensation in the extremities 2Observe for mental status changes every four hours 3Reinforce findings of hypoglycemia when the client asks 4Measure blood pressure, pulse and respirations - Solution 4 When walking past a client's room, the nurse hears an unlicensed assistive person (UAP) talking to another UAP. Which of these statements requires further intervention by the nurse? 1"I'll come back and make the bed after I go to the lab." on the wrong client. Which of the following actions are appropriate for the nurse to take? - Solution Mark the entry as "mistaken entry-wrong patient." Enter the time the error was discovered. The nurse is preparing a client for a colonoscopy and notes that the consent form has not been signed. Which of the following statements by the nurse are appropriate to make to the client? - Solution "Please tell me your full name and date of birth." "Do you have any questions about the colonoscopy?" "Describe what the health care provider told you about a colonoscopy." An outpatient client is scheduled to receive an oral solution of radioactive iodine. In order to reduce radiation exposure to others, which information should the nurse reinforce? 1No solid food may be eaten for six hours after ingestion. 2Urine and saliva will be radioactive for 24 hours after ingestion. 3Wash laundry separately and rinse twice in hot water. 4Wait for 48 hours to have grandchildren visit at home. - Solution 2 The client is diagnosed with active tuberculosis (TB) and the case has been reported to the local health department. The nurse understands that the most important reason for notifying the health department is: 1To ensure that treatment compliance will be monitored 2To trace and screen recent contacts the client had 3To maintain important disease outbreak statistics 4To track the incidence of tuberculosis cases - Solution 2 The parent of a toddler who is being treated for suspected poisoning asks, "Why is activated charcoal used?" What is the best response by the nurse? 1"When the poison is absorbed into the blood stream, the activated charcoal will neutralize it." 2"Activated charcoal binds with the poison to limit absorption in the digestive tract." 3"Activated charcoal causes vomiting, which will eliminate the poison from the body." 4"The activated charcoal will protect the kidneys from any long-lasting damage." - Solution 2 The parents of a toddler ask, "How long will our child have to sit in a car seat when riding in a car?" What would be the best response by the nurse? 1"Until the child is able to sit in a booster seat." 2"Until the child weighs 40 pounds." 3"Until the child outgrows the car seat." 4"Until the child is 50 inches tall." - Solution 3 The nurse has administered haloperidol 5 mg orally (PO) as needed (PRN) to a client with a diagnosis of schizophrenia. Which of the following behaviors justify use of this chemical restraint? - Solution The client is verbalizing a plan to harm another client. The client is expressing paranoid delusions. The client is experiencing command hallucinations. A community health clinic nurse is interviewing a client who is experiencing lightheadedness. The client reports a history of arthritis and is taking naproxen sodium for the pain. The client is pale, the blood pressure is 88/40, pulse is 114, respiratory rate is 22 and temperature is 98.2° F (36.7 C°). What additional information should the nurse solicit from the client? (Select all that apply.) - Solution frequency and amount used color of bowel movements bruising The nurse is discussing modifiable cardiac risk factors with a group of adult clients at a community center. Which topic should the nurse reinforce as the highest priority intervention? 1Increasing physical exercise 2Smoking cessation 3Stress management 4Weight reduction - Solution 2 The home health nurse is seeing a client diagnosed with type 2 diabetes. The client has a small foot ulcer that was debrided and requires daily dressing changes. Which intervention is most important for the nurse to implement to meet the goal of uncomplicated wound closure? 1Schedule regular visits to monitor wound healing. 2Involve the client in making decisions. 3Evaluate the client's understanding of appropriate foot care. 4Arrange for referral to a diabetic educator. - Solution 2 The client is in her first trimester of pregnancy. What major developmental task should the client accomplish during this stage of pregnancy? 1Viewing the fetus as a separate and unique being. 2Accepting the loss of physical intimacy. 3Resolving any fears related to giving birth. 4Accepting physical changes related to pregnancy. - Solution 4 A home health nurse is making an initial visit to a new client. What action should the nurse take first to meet the client's health needs? 1Identify community resources. 2Assist with meal planning. 3Evaluate the home for safety hazards. 4Identify the client's learning needs. - Solution 4 During a well-baby visit, the nurse is evaluating developmental milestones for the 7-month-old child. Which of these developmental activities should the child be able to perform? 1Sits without support 2Uses pincer grasp 3Says several words 4Drinks from a cup - Solution 1 The age at which a child typically develops the ability to sit steadily without support is around 7 to 8 months. Saying several words, drinking from a cup and using a neat pincer grasp are developmental milestones that most children do not reach until age 11 to 12 months. A client is forgetful and experiencing short-term memory loss. While collecting data about short-term memory loss, which action should the nurse take first? 1Ask the client to state his date of birth. 2Confirm that the client's hearing is intact. 3Observe the client while performing an activity. 4Ask the client to name the current U.S. president. - Solution 2 During the physical inspection of a client, the nurse notes a pulsating mass in the client's periumbilical area. Which action should the nurse take next? 1Measure the length of the mass. 2Auscultate the area. 3Palpate the area. 4Percuss the area. - Solution 2 illness. These are sometimes described as features that are "added" by the illness. In contrast, negative symptoms are those that reflect a decrease in normal functions, or abilities that have been "taken away." Positive symptoms of schizophrenia include delusions, hallucinations, hyper vigilance and disorganized thinking. The nurse is providing care for a client who has been diagnosed with terminal cancer. The nurse notes that the client's wife is not visiting very often. When she does visit the client, she only stays for a brief time, stands in the corner and does not approach the client during interactions. Which of the grieving processes is the client's wife most likely experiencing? 1Disenfranchised grief 2Anticipatory grief 3Perceived loss 4Death anxiety - Solution 2 anticipatory grief is the family member becomes distant and detached from the client and the client feels isolated and alone. Death anxiety is worry or fear related to dying that may be seen with a grieving child. Disenfranchised grief is when the individual cannot acknowledge the loss, perhaps because of an unrecognized loss, such as an abortion or a suicide. Perceived loss is a loss that cannot be verified by others such as a loss of self-esteem or a loss of control. The nurse is caring for a postpartum Latina client who keeps declining the hospital food because it is "cold." What action should the nurse take initially? 1Send the food to be reheated. 2Encourage the client to eat for strength. 3Ask the client what foods are acceptable. 4Consult with the dietitian as soon as possible. - Solution 3 An adolescent client is paralyzed from the waist down after being involved in a motor vehicle accident. Which client statement would indicate to the nurse that the client is using repression as an ego defense mechanism? 1"It's all the other driver's fault! They were driving too fast." 2"I don't remember anything about what happened to me." 3"My parents are heartbroken about my situation." 4"I know that I will walk again one day." - Solution 2 Repression is the unconscious and involuntary forgetting of painful events, ideas and conflicts. The nurse is working with a couple who is experiencing intense anxiety after their home was completely destroyed by a fire. The nurse should implement which initial intervention? 1Suggest finding an apartment with a sprinkler system. 2Explore the couple's feelings of grief and loss. 3Determine what community housing resources are available. 4Provide a brochure on relaxation and stress relief. - Solution 3 The couple has experienced a crisis, i.e., sudden loss event that has resulted in disequilibrium. The most important initial crisis intervention focuses on identifying resources and obtaining assistance for housing and other immediate needs. The nurse is evaluating a client who is being physically abused by the client's domestic partner. The client states, "I need a little time away." Which is the most likely response from the partner for which the nurse should prepare the client? 1Fear of rejection, resulting in increased rage toward the client 2Relief over a separation as a way to have some personal time 3Acceptance and understanding that the relationship is in trouble 4A new commitment to seek counseling to assist with problems - Solution 1 A client is admitted to the medical-surgical unit following a motor vehicle accident. Twelve hours after admission the client becomes diaphoretic, tremulous and irritable, and the client's pulse and blood pressure are elevated. The client states to the nurse, "I have to get out of here." What is the most likely cause for the client's symptoms and behavior? 1Dissatisfaction with hospital care 2Anxiety related to being hospitalized 33hock related to the injuries 4Early stage of alcohol withdrawal - Solution 4 signs and symptoms of alcohol withdrawal, such as sweating, tremors, hyperactivity, hypertension and tachycardia. The client most likely wants to leave the hospital to obtain alcohol. The client must be monitored very closely for progression to more severe alcohol withdrawal symptoms, including seizures and delirium tremens (DTs). A client who is taking duloxetine asks the nurse if the medication treats depression or diabetes. What is the best response from the nurse? 1"Duloxetine is used to treat depression but can also be used to lower blood sugar levels." 2"Duloxetine is used to treat depression but can be used to treat pain that can occur in people with diabetes." 3"Duloxetine is not prescribed for either depression or diabetes." 4"Duloxetine is used to treat diabetes but can also be used to treat depression." - Solution 2 Duloxetine is a selective serotonin and norepinephrine reuptake inhibitor (SNRI) that can be used to treat depression but also can be used to treat pain associated with diabetic neuropathy. The nurse is caring for a female client with a body mass index (BMI) of 45. Which conditions should the nurse plan to discuss with the client due to the risks associated with her weight? (Select all that apply.) - Solution obstructive sleep apnea gallstones coronary artery disease breast cancer HYPERTHYROIDISM IS NOT ASSOCIATED WITH BEING OVERWEIGHT OR BMI The nurse is caring for a client diagnosed with substance use disorder (SUD). The client states, "I just drink occasionally. I don't know why my wife and the judge think that I need to be in an alcohol treatment program." Which of the following behaviors are consistent with SUD? (Select all that apply.) - Solution Prone to act impulsively Insecurity in relationships Craving and inability to abstain from alcohol The nurse is caring for a client who has a history of heavy alcohol use. Which findings would indicate that the client is probably experiencing delirium tremens (DTs)? 1Chest pain, nausea, diaphoresis and tachycardia 2Nausea, vomiting, bloody stools and hypotension 3Headache, blurred vision, garbled speech and hypertension 4Excitability, disorientation, tremors and tachycardia - Solution 4 A home health nurse is caring for a client diagnosed with late-stage, Lewy body dementia (LBD). The nurse is meeting with the client's family to discuss options for care of the client. What is the initial question the nurse should ask to assist the family with their decision-making process? 1"What is your opinion of nursing homes or assisted living facilities?" 2"Is your parent currently taking over-the-counter (OTC) or prescription medications?" 3"Are you able to assist with the care of your parent in any manner?" 4"What type of assistance does your parent require?" - Solution 4 The nurse is caring for a client with paraplegia due to a spinal cord injury at the T-7 level. Which nursing intervention should be a priority for this client? 1Obtain a pressure-reducing mattress for the client's bed. 2Observe the client performing self-catheterization correctly. 3Consult with the discharge planner about equipment the client's needs at home. 4Encourage the client to increase intake of fluids and high-fiber foods. - Solution 1 The nurse is evaluating the plan of care for a client with osteoporosis. What type of activity should the nurse reinforce for this client? 1Enroll in a kickboxing class twice a week. 2Walk for 30 minutes, 3 to 5 times a week. 3Participate in swimming lessons three times a week. 4Go jogging 5 to 7 times a week. - Solution 2 Teach the client (or reinforce teaching) that walking for 30 minutes, 3 to 5 times a week, is the single most effective exercise for osteoporosis prevention. The nurse is caring for child diagnosed with celiac disease. Which of the following foods would be an appropriate snack choice for this child? 1A cup of cereal 2A slice of wheat bread 3A cup of yogurt 4An oatmeal cookie - Solution 3 A client is on NPO status and has a nasogastric (NG) tube in place, connected to low-intermittent suction, to help resolve a small bowel obstruction. Which nursing intervention should the nurse implement for this client? 1Allow the client to melt ice chips in their mouth. 2Provide oral care at least every 2 to 4 hours. 3Swab the client's mouth, using glycerin swabs. 4Provide the client mints to freshen their breath. - Solution 2 The nurse is caring for an adult client who suffered second degree burns over 25% of their body in a house fire. Which observation best indicates that fluid resuscitation has been effective? 1Elastic, nontenting skin turgor 2Moist oral mucus membranes 3Urine output of 35 mL per hour 4No reports of thirst - Solution 3 The goal is to maintain an hourly urine output of 0.5 mL/hour (about 30 mL/hour) for the average adult. Which of the following actions by the nurse indicates a need for additional education on the prevention of health care-associated infections (HAIs)? 1The nurse uses their own stethoscope to assess the lung sounds of a client placed on contact precautions for Methicillin-resistant Staphylococcus aureus (MRSA) infection. 2The nurse calls the health care provider (HCP) to request the removal of the indwelling urinary catheter for a two days postoperative client. 3The nurse cleanses hands with soap and water for 60 seconds after caring for a client with Clostridium difficile (C. difficile) infection. 4The nurse wears a gown and gloves when providing perineal care to a client with Vancomycin-resistant Enterococci (VRE) infection. - Solution 1 A client has been diagnosed with dysphagia due to a stroke. What nursing intervention should the nurse implement for this client? 1Instruct the client to tilt their head back while swallowing. 2Position the client in an upright position while they are eating. 3Assist the client to drink through a straw. 4Instruct the client to use sips of water to help wash down food. - Solution 2 A client is transferred from the postanesthesia care unit (PACU) to the medical-surgical unit after an appendectomy. Which action should the nurse on the medical-surgical unit perform first? 1Ask the client about pain. 2Orient the client to the unit. 3Review the postoperative orders. 4Take the client's vital signs. - Solution 4 The nurse is evaluating the effectiveness of a bowel training program for a client with chronic constipation. Which statements made by the client should the LPN/VN report to the RN for additional teaching? - Solution Bowel training programs are designed to return defecation to normal. Fluid intake should be 2.5 to 3 liters per day. The client should increase fiber in their diet, and intake hot drinks just prior to their normal bowel elimination time to facilitate normal bowel function. A suppository treatment should be administered about half an hour before the client's normal bowel elimination time—inserting it just prior to bedtime will disturb the client's sleep pattern. The client should be provided with privacy for about 30 to 40 minutes and should sit on a commode or bedpan whenever they have the urge to defecate. An obese client tells the nurse, "I just started a diet and I am eating no more than 800 calories a day." What information should the nurse reinforce with the client? 1Very low-calorie diets often have severe and irreversible side effects. 2Very low-calorie diets are adequate if balanced with fruits and vegetables. 3Very low-calorie diets are intended for short-term use only. 4Very low-calorie diets are appropriate for long-term weight management. - Solution 3 A 2-year-old child is brought to the pediatrician's office by the parents, who report that the child has been having diarrhea for two days. What nutritional information should the nurse provide to the parents? 1Keep the child fasting, give them nothing to eat, and return the next day. 2Give the child only clear liquids and gelatin for 24 hours. 3Continue a regular diet and add electrolyte replacement drinks. 4Give the child bananas, apples, rice and toast as tolerated. - Solution 3 The nurse is providing care to an older adult client diagnosed with bilateral pneumonia. Which intervention should the nurse implement to best promote the client's comfort? 1Encourage visits from family and friends. 2Keep conversations short. 3Increase the client's oral fluid intake. 4Monitor vital signs frequently. - Solution 2 3The client has a history of acid reflux disease. 4The client has a history of urinary retention. - Solution 2 they are excreted by glomerular filtration. Aminoglycosides are nephrotoxic and requires close monitoring of renal function. A client with chronic kidney disease should not receive this medication. The nurse in a long-term care facility is preparing to administer medications. Which physiological changes does the nurse know will affect medication pharmacokinetics in older adults? 1Due to an increase in glomerular filtration rates, medications are excreted more rapidly. 2Due to a decrease in gastric emptying, higher medication doses are prescribed. 3Due to a decrease in renal drug excretion, a greater risk for adverse medication effects exist. 4Due to an increase in metabolism, medications are prescribed more frequently. - Solution 3 The nurse prepares to administer a liquid medication to an infant. At the bedside, the parent states that the infant does not like to take medications. Which action should the nurse perform to ease the medication administration? 1Use an oral syringe to administer the medication, alternating with a pacifier. 2Mix the liquid medication with a full bottle of formula. 3Give half the dose now and the remaining amount in an hour. 4Ask the health care provider (HCP) to switch the medication to an injection. - Solution 1 A client is admitted with deep vein thrombosis (DVT). The health care provider (HCP) orders the immediate administration of an intravenous bolus of heparin sodium 200 units/kg . The client weighs 187 lbs. How many mL should the nurse draw up from the supplied 10 mL vial that contains 5,000 units per mL? Do not round. - Solution 3.4 The nurse has given discharge instructions to a client who suffers from sensory neuropathy due to diabetes. The client was prescribed gabapentin. Which of the following statements indicates that the client understands the nurse's instructions regarding the medication? 1"I can stop taking the medication at any time." 2"It is safe to take extra doses if my pain becomes worse." 3"The medication might cause me to have insomnia." 4"My doctor prescribed it for the pain in my legs." - Solution 4 The nurse is reviewing medication orders for a client who has requested something for pain. In the process, the nurse finds a new written order for a pain medication. The health care provider (HCP) wrote, "Give APAP every six hours as needed for pain." Which parts of the medication order should the nurse clarify before administering the medication? - Solution route drug name dosage The nurse administers a medication to the wrong client. Which action(s) should the nurse take when the medication error is identified? (Select all that apply.) - Solution Notify health care provider Complete an incident report Monitor the client for adverse effects Document the error in the medical record A client recovering from hip replacement surgery is taking acetaminophen with codeine every three hours for pain. For which side effect should the nurse monitor the client? 1Diffuse rash 2Constipation 3Wheezing 4Hyperglycemia - Solution 2 A client is prescribed trimethoprim/sulfamethoxazole for recurrent urinary tract infections. Which statement by the nurse about this medication is correct? 1"You can stop the medication after five days." 2"Be sure to take the medication with food." 3"Drink at least eight glasses of water a day." 4"It is safe to take with oral contraceptives." - Solution 3 Unlike many other antibiotics, trimethoprim/sulfamethoxazole does not seem to affect hormonal birth control such as the pill, the patch or ring. The hospice nurse is visiting a client diagnosed with end-stage lung cancer and metastases to the bone. What should the nurse keep in mind when planning for effective pain management? 1Relief of pain will be achieved quickly. 2Pain therapy is based on the client's report of pain. 3High doses of opioid analgesics will be required. 4The client will most likely become addicted. - Solution 2 The nurse is discharging a client who is at risk for venous thromboembolism (VTE). The client is prescribed enoxaparin. Which instruction should the nurse provide to this client? 1"Notify your health care provider if your stools appear tarry or black." 2"You should massage the injection site for better absorption." 3"An intravenous (IV) catheter will be placed to administer the medication." 4"You must have your partial thromboplastin time (PTT) checked weekly." - Solution 1 As with any anticoagulant, enoxaparin carries the risk of bleeding. Clients should be instructed to report the presence of tarry stools, bleeding gums, hematuria, ecchymosis or petechiae to their HCP A client who has been diagnosed with Raynaud's disease and hypertension is prescribed nifedipine. For which side effect should the nurse monitor the client? 1Decreased urine output 2Facial flushing 3Cyanosis of the lips 4Increased pain in fingers - Solution 2 Nifedipine is a calcium channel blocker (CCB) used in the treatment of Raynaud's disease and hypertension by producing vasodilation. As a result of this vasodilating effect, facial flushing can occur. A postoperative client has a prescription for acetaminophen with codeine for pain relief. The nurse understands which action to be the primary purpose of this drug combination? 1Faster onset of action 2Minimized side effects 3Enhanced pain relief 4Prevents tolerance - Solution A client diagnosed with tuberculosis is prescribed rifampin and isoniazid. Which information should the nurse include when reinforcing information about these medications? 1"You may have occasional problems sleeping." ill may become temporarily confused while taking H2 blockers, especially cimetidine. A client at risk for a stroke has been prescribed clopidogrel. Which information is most important for the nurse to reinforce with the client? 1"You must take the medication on an empty stomach." 2"If you miss a dose, take a double dose the next day." 3"You must have your lab tests checked weekly." 4"You must stop the medication a week before your surgery." - Solution 4 Clopidogrel is an oral antiplatelet drug with similar effects to aspirin. The drug is taken for secondary prevention of myocardial infarction, ischemic stroke and other vascular events. Clopidogrel prevents platelet aggregation. Like all other antiplatelet drugs, clopidogrel poses a risk of serious bleeding. Clopidogrel should be discontinued 5 to 7 days before elective surgery. The nurse is reinforcing the correct use of a metered-dose inhaler (MDI) for a client newly-diagnosed with asthma. The client asks, "how will I know the canister is empty?" What is the best response by the nurse? 1"Drop the canister in water to observe if it floats." 2"Contact your pharmacy to find out when to obtain a refill." 3"Count the number of doses as the inhaler is used." 4"Shake the canister and listen for any fluid movement." - Solution 3 A client is prescribed furosemide and digoxin for heart failure. The nurse should monitor the client for which potential adverse drug effect? 1Pulmonary hypertension 2Acute arterial occlusion 3Cardiac dysrhythmias 4Acute kidney injury - Solution 3 Digoxin is a cardiac glycoside, or positive inotrope that increases myocardial contractility. By increasing contractile force, digoxin can increase cardiac output in clients with heart failure (HF). Furosemide is a potassium-wasting (loop) diuretic, prescribed to prevent fluid overload in clients with HF. Clients who take furosemide are at risk for developing hypokalemia. Potassium ions compete with digoxin and a low potassium level can cause digoxin toxicity, leading to lethal cardiac dysrhythmias. Therefore, it is imperative that potassium levels be kept within normal range (3.5 to 5 mEq/L) while taking digoxin. The nurse in an ambulatory clinic is speaking with the parents of a 2-year- old child diagnosed with acute otitis media. Which information is most important for the nurse to include in the instructions to the parents? 1The child must complete the entire course of the prescribed antibiotic. 2The child may be given a decongestant to relieve pressure on the tympanic membrane. 3The child should return to the clinic to evaluate effectiveness of the treatment. 4The child may be given acetaminophen or ibuprofen drops for pain. - Solution 1 The nurse is reinforcing teaching about levothyroxine for a client newly- diagnosed with hypothyroidism. Which information should the nurse make sure to reinforce about this medication? 1The medication may decrease the client's energy level. 2The medication will decrease the client's heart rate. 3The medication should be taken in the morning. 4The medication must be stored in a dark container. - Solution 3 A thyroid supplement, such as levothyroxine, should be taken on an empty stomach in the morning. Morning dosing minimizes the side effect of insomnia and an empty stomach facilitates absorption. Levothyroxine will cause an increase in the client's energy level and heart rate. A client received hydromorphone orally one hour ago. When the nurse enters the client's room, the client is unresponsive to verbal stimuli and has a respiratory rate of six. Which action should the nurse take next? 1Prepare for endotracheal intubation. 2Administer supplemental oxygen. 3Begin cardiopulmonary resuscitation. 4Prepare to administer naloxone. - Solution 4 A client has been prescribed alendronate for osteoporosis. Which of the following statements indicate the client understands how to safely take this medication? (Select all that apply.) - Solution Alendronate is a bisphosphonate used to treat osteoporosis. It can cause esophagitis or esophageal ulcers unless precautions are followed. The client must sit upright or stand for at least 30 minutes after taking the medication. The client should take the medication with a full glass of water, at least 30 minutes before eating or drinking anything or taking any other medication. Antacids will interfere with absorption and should not be taken at the same time. The nurse observes a new nurse administering a rectal suppository to a client. Which actions are appropriate for the new nurse to implement? (Select all that apply.) - Solution The nurse pushes the suppository in, up to the second knuckle. The nurse applies water-soluble lubricant to the suppository. The nurse places the client on the left side during insertion. After 10 minutes, the nurse turns the client to the right side. A nurse is caring for a client who was recently admitted following an episode of status epilepticus. Which of the following data is most important to collect? 1Level of consciousness (LOC) 2Amount of intravenous fluid infused 3Pulse and blood pressure 4Injuries to the extremities - Solution 1 The nurse is preparing a client for an intravenous pyelogram (IVP) test. What information is most important for the nurse to obtain prior to the procedure? 1Time of the client's last meal 2History of allergies 3Amount of urine output 4BUN and creatinine level - Solution 2 An older adult client, diagnosed with active pulmonary tuberculosis, has difficulty in coughing up secretions for a sputum specimen. Which nursing intervention would be most helpful for this client? 1Encourage client to ambulate frequently. 2Spray the oropharynx with saline. 3Administer a nebulizer treatment. 4Push fluids for the next eight hours. - Solution 3 It is important for the large intestine to be clear of stool to allow full visualization of the kidney, bladder and ureters. The nurse is preparing to suction a client's tracheostomy. What action should the nurse take to prevent hypoxia during the procedure? 1Explain procedure to client. 2Monitor heart rate during suctioning. 3Use sterile technique. 4Provide preoxygenation to the client. - Solution 4 The nurse is caring for a comatose client. To prevent keratitis, moisturizing ointment should be prescribed for which body site? 1Lower eyelids 2External ear canal 3Fingernails and toenails 4Perianal area - Solution 1 Unconscious or comatose clients are often unable to close their eyes or do not have a functioning blink reflex. When the eye remains open for a prolonged time, the cornea will dry out, causing irritation or ulceration. The nurse is in the process of inserting a urinary catheter in an adult female client. The nurse advances the catheter approximately 2 to 3 inches (5 to 7 cm), but no urine return is seen. What should the nurse do next? 1Inflate the catheter balloon. 2Advance the catheter a few more inches. 3Withdraw the catheter and try again. 4Notify the health care provider (HCP). - Solution 2 A child diagnosed with thalassemia has received several blood transfusions during the past three days. What lab value is the priority for the nurse to monitor with this client? 1Hemoglobin level 2Platelet count 3Blood urea nitrogen level 4Neutrophil percentage - Solution 1 A normal hemoglobin range for children is approximately 11 to 13 gm/dL. Thalassemia, also called Cooley's anemia, is a genetic defect that causes anemia, i.e., a condition in which the blood contains below-normal hemoglobin levels. Hemoglobin is the oxygen-carrying protein component of the red blood cell (RBC). The nurse initiates continuous enteral feeding at 8 am at 50 mL/hour for a client with malnutrition. It is now noon. What priority action should the nurse take at this time? 1Flush the feeding tube with 100 mL of water. 2Assess bowel sounds and gastric pH. 3Measure the gastric residual volume. 4Keep head of bed elevated at least 30 degrees. - Solution 3 A transesophageal echocardiogram (TEE) is ordered for a client with possible endocarditis. Which action included in the TEE orders should the nurse implement first? 1Place the client on NPO status. 2Administer O2 per nasal cannula. 3Start a peripheral IV line. 4Give midazolam (Versed) 1 mg IV push. - Solution 1 A pregnant woman in the third trimester is admitted with a report of painless vaginal bleeding that started several hours ago. The nurse should prepare the client for what procedure? 1Pelvic exam 2Abdominal ultrasound 3Nonstress test 4Caesarean section - Solution 2 A client has been taking isoniazid (INH) and rifampin for several months. Which laboratory test should the nurse monitor with this client? 1Creatinine clearance 2Cardiac enzymes 3Liver enzymes 4Sputum culture - Solution 3 INH and rifampin are used to treat tuberculosis and both are hepatotoxic. Isoniazid can cause hepatocellular injury A male client underwent a hernia repair in an outpatient surgery clinic. He is awake and alert, but has not been able to void since he returned from surgery six hours ago. He received 1000 mL of intravenous (IV) fluids. Which action should the nurse implement to help this client urinate? 1Have the client drink several glasses of water. 2Insert a urinary catheter. 3Assist the client to stand to void. 4Obtain a bladder ultrasound. - Solution 3 The nurse is caring for a client who had a closed reduction of a fractured right wrist, followed by the application of a cast about 12 hours ago. Which finding requires the nurse's immediate attention? 1Serum calcium level of 6.8 mg/dL 2Numbness in the right hand 3Reported pain level of six on a numeric pain scale 4Edema and swelling of the right hand - Solution 2 A nurse is caring for a client who had a cholecystectomy with common bile duct exploration and placement of a T-tube 24 hours ago. The nurse observes large amounts of bilious drainage from the T-tube. Which action should the nurse take? 1Administer pain medication. 2Clamp the T-tube for two hours. 3Continue to monitor the drainage. 4Lower the head of the bed. - Solution 3 A client is admitted to the hospital with endocarditis. The nurse understands that which risk factors can lead to the development of endocarditis? (Select all that apply.) - Solution Oral abscess with tooth extraction History of aortic valve replacement Placement of an arteriovenous fistula for hemodialysis Placement of a central venous access device The nurse is reviewing the chart of a client who was recently diagnosed with coronary artery disease due to atherosclerosis. Which factors most likely contributed to the development of this disease? (Select all that apply.) - Solution Mother died of a myocardial infarction Low-density lipoprotein (LDL) level of 149 mg/dL History of diabetes mellitus Used to smoke 40 packs per year until one year ago The target LDL level for a client is less than 100 mg/dL. The nurse is evaluating a client who was admitted for a small bowel obstruction and dehydration. Which observation by the nurse would indicate that the dehydration is improving? A client with a history of chronic alcohol use disorder is admitted to the inpatient unit with a serum magnesium level of 1.0 mEq/L. Which intervention should the nurse implement first? 1Assess the client's deep tendon reflexes. 2Order the client a meal with foods high in magnesium. 3Obtain the client's heart rate and oxygen saturation. 4Place the client on fall risk and seizure precautions. - Solution 3 The nurse administered furosemide to a client with acute pulmonary edema. Which observation by the nurse would indicate that the client is experiencing an adverse side effect of the medication? 1The client exhibits exertional dyspnea with walking. 2The client reports muscle cramps in both legs. 3The client's blood pressure is 104/60 mm Hg. 4The client's weight decreased by 2 lbs. in two days. - Solution 2 Muscle cramps and spasms while receiving diuretic therapy could indicate hypokalemia, an adverse drug effect of furosemide because this is a potassium wasting diuretic The nurse is reviewing the plan of care for a client with peripheral artery disease who has a history of leg pain with walking. Which interventions should the nurse include in the client's plan of care? (Select all that apply). - Solution Enroll the client in an exercise program that involves low-impact activities. Assist the client in selecting food items that are low in saturated fats and cholesterol. Reinforce teaching on the importance of not walking without shoes on. Assist the client in enrolling in a smoking cessation program. The nurse is caring for a client admitted with sickle cell crisis. Which medication is the drug of choice for pain management with this client? 1Meperidine 2Ibuprofen 3Acetaminophen 4Hydromorphone - Solution 4 The nurse is planning care for a client newly diagnosed with essential hypertension. Which interventions should the nurse include in the client's plan of care? (Select all that apply.) - Solution Encourage the client to take daily, 30-minute walks. Explain the negative effects of hypertension on Evaluate the client's understanding of a low-sodium diet. Evaluate the client's ability to take their own blood pressure. The nurse is assisting in developing a plan of care for a client who is on complete bedrest due to a spinal cord injury. Which intervention is most important for the nurse to include? 1Apply pneumatic compression devices to both legs. 2Turn and reposition the client every shift. 3Insert an indwelling urinary catheter. 4Administer a daily enema. - Solution 1 The nurse is reinforcing teaching for a client who was newly diagnosed with asthma. Clients with asthma should demonstrate understanding of which of the following? (Select all that apply.) - Solution Clients must understand the use of medications including quick-relief (rescue) and long-acting (maintenance) therapies. Clients use the peak flow meter to assess effectiveness of medication or breathing status. An acute attack can be a medical emergency and knowing where and how to seek medical care is important. Certain conditions (triggers) can exacerbate an attack and should be avoided. A client is seen at the primary care clinic for allergic rhinitis. Which clinical manifestations should the nurse expect with this diagnosis? (Select all that apply.) - Solution Common symptoms of allergic rhinitis are due primarily to the release of immune mediators such as histamine, prostaglandins, eosinophils and cytokines. This leads to sneezing, runny nose with clear discharge, nasal congestion and an increased eosinophil counts. Symptoms may appear similar to a cold. Due to drainage, the client's sense of smell can be altered. The nurse is caring for a client with a dry chest tube drainage system due to a left tension pneumothorax. Two hours ago, the health care provider (HCP) changed the chest tube prescription to water seal only. When entering the client's room, the nurse finds the client to be short of breath, tachypneic and with an oxygen saturation (SpO2) of 84%. On auscultation, the nurse notes absent breath sounds to the left upper lobe. What action should the nurse take first? 1Apply oxygen via nasal cannula 2Document all interventions in the client's medical record 3Notify the appropriate HCP 4Request a chest X-ray - Solution 1 The nurse is planning care for a client admitted to the hospital with influenza. Which interventions should the nurse include in the client's plan of care? (Select all that apply.) - Solution Antiviral agents, such as oseltamivir, are used to shorten the course and reduce symptoms of the flu. Droplet transmission-based precautions are indicated to prevent the spread of the flu. To avoid further transmission of the illness, visitors with signs/symptoms of a respiratory illness should not be permitted on the unit. It is important to ensure that clients understand how to prevent transmission of infections such as the flu through proper hand hygiene and cough etiquette. A client has been diagnosed with emphysema. Which intervention should the nurse implement when caring for this client? 1Inquire if the client has a power of attorney for health care. 2Reassure the client that the lung damage is usually reversible. 3Schedule a lung cancer screening for the client. 4Assist the client with enrolling in a smoking cessation program. - Solution 4 A nurse is administering the influenza vaccine in an occupational health clinic. Within 10 minutes of giving the vaccine to a middle-aged adult male, the man reports having itchy and watery eyes, feeling anxious and short of breath. What should the nurse do first? 1Administer SQ epinephrine. 2Maintain the airway. 3Take the client's vital signs. 4Apply oxygen. - Solution 1 4Nutritional deficits - Solution 1 The nurse is providing care to an 80-year-old client with the diagnosis of advanced Parkinson's disease. The nurse should know that the greatest risk to the client is related to which finding? 1Difficulties with reading and seeing at night 2Extreme weakness in the lower extremities 3Drooling and coughing when eating 4Dizziness and syncopal episodes - Solution 3 The home health nurse is reviewing the plan of care for a client experiencing acute attacks of Ménière's disease. What is the priority intervention for this client? 1Instruct the client not to drive a motor vehicle. 2Provide assistance with bathing and dressing. 3Communicate clearly and use visual aids. 4Encourage bland foods and noncarbonated fluids. - Solution 1 The nurse on the inpatient unit is expecting the admission of a client with a new onset of seizures and instructs the unlicensed assistive person (UAP) to prepare the client's room. Which piece of equipment should the UAP make sure to place in the room? 1Soft wrist restraints 2An oral airway 3A bedside commode 4Pads to be placed over the bed's side rails - Solution 4 The nurse is reinforcing discharge instructions for a client after cataract surgery of the left eye. Which statements by the client indicate an understanding of the instructions? (Select all that apply.) - Solution "I will follow the instructions for the eye drops." "I will call the surgeon if the pain is intense." "I will not rub, press on or scratch my eye." The nurse is providing care for a 40-year-old client suspected of having Guillain-Barré syndrome. Which intervention should the nurse plan for? 1Genetic testing of the client's children 2A bone marrow biopsy 3Administration of immunoglobulins 4Implementation of airborne precautions - Solution 3 Intravenous immunoglobulins (IV Ig) are used to treat Guillain-Barré in the early phase. They are believed to interfere with antigen presentation and help to modulate the body's immune response. The nurse in the neurology office is reviewing information about levetiracetam with a 30-year-old female client with a history of seizures. Which instruction about the medication should the nurse make sure to include? 1"You might experience irregular menses and intermittent bleeding." 2"Call the office immediately if you feel like hurting or killing yourself." 3"You should stay away from large crowds and sick children." 4"You should avoid becoming pregnant while taking this medication." - Solution 2 Levetiracetam is an anti-convulsant medication used to prevent seizures. One of the significant side effects is behavioral changes and suicidal ideations. The nurse is performing a home visit for an older adult client with Alzheimer's disease. Which of the following observations should be a priority for the nurse to address? 1Good lighting in the stairwell 2Throw rugs on the kitchen floor 3Lamps plugged directly into wall outlets 4Handrails in the bathtub - Solution 2 The nurse is collecting data from a college student who comes to the health clinic with symptoms of meningitis. The student resides in the school dormitory. What is the priority action the nurse should take? 1Perform a focused neurological assessment. 2Administer acetaminophen for the headache. 3Alert the college's administration and dormitory staff. 4Obtain the client's immunization history. - Solution 3 The clinic nurse is following up with a client who was seen a few days ago for trigeminal neuralgia. Which action by the client indicates an understanding of how to manage the condition? 1Takes an analgesic after performing household chores. 2Keeps the environment at a moderate temperature and free from drafts. 3Eats a bowl of hot, steaming soup every day for lunch. 4Performs vigorous brushing of teeth twice per day. - Solution 2 Trigeminal neuralgia is a disruption in the cranial nerve and causes sudden, severe, brief stabbing pain. Keeping the environment at a moderate temperature and free from drafts can reduce the risk of triggering an acute attack. The nurse in the long-term care facility is reviewing the plan of care for a client with Parkinson's disease. Which interventions should the nurse make sure to include for this client? (Select all that apply.) - Solution Set-up a bladder training program for the client. Encourage participation in speech therapy. Use cognitive strategies to enhance the client's memory. Provide assistance with ambulation. The nurse is reviewing the plan of care for a 30-year-old client newly diagnosed with multiple sclerosis. Which interventions should the nurse include for this client? (Select all that apply.) Instruct the client on how to self-catheterize as needed. Review methods to prevent and treat constipation. Encourage participation in physical and occupational therapy. Encourage participation in vocational rehabilitation. Encourage independence in personal care and bathing. - Solution Review methods to prevent and treat constipation. Encourage participation in physical and occupational therapy. Encourage participation in vocational rehabilitation. Encourage independence in personal care and bathing. "Make sure to drink the entire bowel preparation liquid." - Solution "You will have an intravenous catheter inserted prior to the procedure." "You should only consume clear liquids for the next 12 to 24 hours." "Remember to stop eating any food six hours before you come to the center." "Make sure to drink the entire bowel preparation liquid." A client is being admitted to the hospital with complaints of bloody stools for several days. Which interventions should the nurse expect to be prescribed for this client? (Select all that apply.) - Solution Administration of pantoprazole Collection of a stool sample for occult blood testing Discontinuation of all NSAID medications The nurse is reinforcing teaching with a client regarding their diagnosis of hepatic encephalopathy. Which statement by the client indicates that additional teaching is needed? 1"I will brush my teeth with a soft toothbrush to avoid bleeding gums." 2"I will eat enough protein and calories to stay healthy." 3"I will stop taking ibuprofen for my knee and back pain." 4"I will stop taking my lactulose when I have more than one loose stool." - Solution 4 The nurse is assisting with meal planning for a client with cholelithiasis. Which food items would be most appropriate for this client? (Select all that apply.) - Solution The most common cause of gallbladder disease is from stones that block the biliary ducts. Other causes are due to inflammation, infection, tumors or decreased blood flow due to damaged vessels. Intake of high cholesterol or fatty foods can increase the risk of gallbladder inflammation. To avoid inflammation, the client should follow a low cholesterol, low-fat diet and limit their intake of fried and processed foods such as breakfast cereals, lunch meats and microwavable meals. The nurse is assigned to care for a client with end-stage liver failure and portal hypertension. Which clinical manifestations would the nurse expect to see with these conditions? (Select all that apply.) Diminished pedal pulses Shortness of breath Increased weight gain Increased abdominal girth Elevated serum albumin level - Solution Shortness of breath Increased weight gain Increased abdominal girth Which discharge instruction should the nurse make sure to include for a client with chronic pancreatitis? 1"Make sure to eat a low-fat, high-fiber diet." 2"Try to reduce smoking cigarettes to half a pack per day." 3"Limit alcohol intake to one drink a day." 4"Take the prescribed pancreatic enzymes on an empty stomach." - Solution 1 The nurse is assisting in developing as plan of care for a postoperative client following a radical left mastectomy. Which nursing problem should be the priority for this client? 1Risk of infection of the surgical site 2Anxiety related to the cancer diagnosis 3Acute pain related to the surgery 4Impaired left arm circulation (lymphedema) - Solution 3 The nurse is evaluating a client's understanding of appropriate dietary choices with chronic kidney disease. Which food choices by the client indicate an understanding of the teaching? (Select all that apply.) Fresh apples Baked chicken Unsalted pretzels Slice of cheese Orange juice Baked potato - Solution Fresh apples Baked chicken Unsalted pretzels A client with chronic kidney disease (CKD) must limit intake of potassium, sodium, phosphorus and protein. In CKD, the kidneys are unable to adequately excrete these components. Foods low in potassium include: apples, grapes, lettuce and cauliflower. Foods high in potassium include: bananas, oranges, potatoes and spinach. Foods low in phosphorus include: chicken, shrimp, crab and rice. Foods high in phosphorus include: organ meats, salmon, scallops, nuts and cheese. A client comes to the community health clinic with symptoms of gonorrhea. Which intervention should the nurse implement first? 1Discuss the risk of infertility with the client. 2Collect a urethral swab from the client. 3Instruct the client to notify past sexual partners. 4Obtain information about the client's recent sexual encounters. - Solution 4 The nurse is assisting with developing a plan of care for a client with benign prostatic hyperplasia. Which nursing interventions should the nurse include for this client? (Select all that apply.) Limit caffeinated and alcoholic beverages. Calculate accurate intake and output. Void every 1 to 2 hours to empty the bladder. Catheterize as needed for post-void residual urine. Monitor for bladder distention. - Solution limit caffeine catheterize as needed monitor The nurse is reviewing the medical record of a client admitted with acute kidney injury. Which findings would support this diagnosis? (Select all that apply.) Proteinuria Hypokalemia Elevated creatinine level Decreased glomerular filtration rate Hematuria Decreased blood area nitrogen - Solution proteinuria elevated creatinine decreased function 4Review when the last dose of insulin was given. - Solution 1 The nurse in the primary health care provider's office is speaking with a 40- year-old male client whose most recent hemoglobin A1C level was 9%. The client states that he is motivated to make lifestyle changes to better manage his disease. What interventions should the nurse recommend for this client? (Select all that apply.) Eliminate all consumption of alcohol. Minimize intake of caffeinated beverages. Schedule an appointment with a registered dietitian. Start a weight loss program until BMI is below 25. Check the blood sugar several times a day, ideally before eating. Engage in regular physical activity, such as walking. - Solution Schedule an appointment with a registered dietitian. Start a weight loss program until BMI is below 25. Check the blood sugar several times a day, ideally before eating. Engage in regular physical activity, such as walking. The nurse is reinforcing education for a client with type 2 diabetes mellitus who is being discharged home. Which statement by the client would require clarification from the nurse? 1"At home, I should check my blood sugar before meals and at bedtime." 2"It is important to increase my physical activity gradually." 3"I will make sure to have an eye exam every five years." 4"When I administer my insulin, I will rotate injection sites." - Solution 3 Eye exams should be performed annually for diabetic clients due to the risk of diabetic retinopathy. The nurse is caring for a client who has suspected Cushing's disease. The nurse should monitor for which potential symptoms? (Select all that apply.) Large fat pads on the back and shoulders History of pathologic fractures Tachycardia and panic attacks Changes in visual acuity Polyuria and polydipsia - Solution Large fat pads on the back and shoulders History of pathologic fractures Cushing's disease occurs when there is an excess amount of cortisol. The nurse must understand that glucocorticoids, including cortisol, regulate metabolism and immune function, and play a role in the regulation and distribution of serum calcium levels. Therefore, deposition of fat pads on the back and shoulders, as well as fractures secondary to osteoporosis, are signs and symptoms of Cushing's disease that the nurse should be able to recognize. The nurse is caring for a client who was admitted for hyperglycemic hyperosmolar state (HHS). Which clinical finding would support this diagnosis? 1Blood sugar > 600 mg/dL 2Positive urine ketones 3Deep, rapid breathing pattern 4Serum pH level < 7.35 - Solution 1 A client diagnosed with hypoparathyroidism would be most likely to display which of the following symptoms? 1Pruritus 2Flank pain 3Decreased reflexes 4Polydipsia - Solution 1 The nurse is caring for a client with diabetes who was admitted for intractable vomiting. The nurse notes that the client's skin is cool to the touch, and the fingerstick blood sugar result is 55 mg/dL. What intervention should the nurse implement first? 1Administer glucagon. 2Recheck the blood sugar in 15 minutes. 3Offer the client a warm blanket. 4Administer an antiemetic. - Solution 1 The nurse is reviewing the plan of care for a client with acute adrenocortical insufficiency. Which intervention should be a priority for this client? 1Administration of potassium supplements 2Electrocardiogram monitoring 3Implementation of a low-sodium diet 4Administration of insulin - Solution 2 The nurse understands that the prescribed levothyroxine is effective when the client with hypothyroidism makes which statement? 1"I still feel lethargic and fatigued." 2"I have been having daily, formed bowel movements." 3"I have to change my sheets in the morning because I sweat a lot at night." 4"I was reprimanded at work after becoming angry with my boss." - Solution 2 The nurse is caring for a client who presents with polyuria, polydipsia and a urine specific gravity of 1.002. The nurse suspects that the client is experiencing diabetes insipidus. Which risk factors would support this diagnosis? (Select all that apply.) Recent neurologic injury Current use of lithium History of recent surgery History of radiation treatment History of pulmonary disease - Solution Recent neurologic injury Current use of lithium History of recent surgery History of radiation treatment The nurse is planning care for a client admitted with uncontrolled hyperglycemia. Which activities can the nurse delegate to the unlicensed assistive person (UAP)? (Select all that apply.) Soak the client's feet in warm water prior to performing nail care. Administer insulin, but do not aspirate for blood prior to injecting. Report any skin lesions or breakdown to the nurse. Cut the client's toenails short and trim the corners with cuticle scissors. Apply moisturizing cream between the client's toes. After bathing, ensure that the client's skin is completely dry. Check the client's blood sugar before meals and at bedtime. - Solution Report any skin lesions or breakdown to the nurse. After bathing, ensure that the client's skin is completely dry. Check the client's blood sugar before meals and at bedtime. The nurse is caring for a client who has been diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). Which interventions are appropriate for this client? (Select all that apply.) Monitoring of intake and output Administration of a loop diuretic Implementation of a fluid restriction Implementation of a low-sodium diet Soaking in a hot bathtub or doing hydrotherapy with physical therapy provides warmth that will decrease pain. The buoyancy of the client's body in water decreases weight on the joints, which will also decrease pain. The nurse in the urgent care clinic is reinforcing teaching for a client who is being discharged with a new cast on the left arm due to a spiral fracture. Which statement indicates that the client correctly understands how to care for the cast? 1"I will avoid using ice the first 24 hours that my cast is on." 2"A moderate amount of daily drainage from my cast is expected." 3"I will notify my health care provider if my hand becomes pale." 4"I should be able to fit three fingers between the cast and my skin." - Solution 3 The nurse is assisting in the admission of a 73-year-old client who has a fractured right hip. Which interventions should the nurse include in the client's plan of care? (Select all that apply.) Ask about the client's pain level with every set of vital signs. Perform daily circulation, motion and sensation checks on the client's right leg. Palpate the client's bilateral pedal pulses every four hours. Place the client on continuous pulse oximetry. Reposition the client every hour to prevent skin breakdown. - Solution The client with a hip fracture is at risk for impaired perfusion to the affected extremity. Monitoring bilateral pedal pulses allows the nurse to compare the pulse strength in the injured site with that in the non-injured site. A decrease in the injured leg could signal a decrease in circulation that would require immediate intervention. A fat embolism is also a risk with a hip fracture and continuous pulse oximetry would allow the nurse to identify hypoxia quickly which could be associated with a fat embolism. Clients with a hip fracture usually experience great pain and assessing pain with each set of vital signs is key to effective pain management. Circulation, motion and sensation checks should be completed at least every four hours, not daily. The nurse is assisting in the preoperative plan of care for an older adult client who will be undergoing a total hip arthroplasty. To improve the client's postoperative course, which interventions should the nurse plan for? (Select all that apply.) Preoperative pain control with naproxen Instruction on plantar and dorsiflexion exercises Administration of subcutaneous warfarin The use of assistive devices for ambulation Application of sequential compression devices - Solution Due to the client's age and the surgical procedure, the client is at risk for a venous thromboembolism. The nurse should include the use of sequential compression devices to decrease venous stasis along with providing instruction on plantar and dorsiflexion exercises. Warfarin is administered orally; it does not come in an injectable form. The client will most likely need assistive devices initially for safe ambulation postoperatively. Preoperatively, the nurse should not use naproxen to control pain because it is a nonsteroidal anti-inflammatory drug (NSAID) and can increase the risk of bleeding during surgery. The nurse is caring for a client who is experiencing an acute gout attack. Which action should the nurse implement? 1Monitor liver enzymes. 2Provide a high-protein diet. 3Restrict sodium intake. 4Administer indomethacin. - Solution 4 the nurse should administer a non-steroidal anti-inflammatory medication such as indomethacin to help decrease pain and inflammation. The nurse is reinforcing teaching regarding the use of methotrexate with a female client who has systemic lupus erythematosus. Which statement by the client indicates an understanding of the teaching? 1"I should not use contraception that contains estrogen." 2"I will avoid interacting with people in large crowds." 3"Lab work won't be necessary while I take this medication." 4"I will not take any vitamin that contains folic acid." - Solution 2 Methotrexate is an immunosuppressant medication that is used to treat systemic lupus erythematosus (SLE). Due to immunosuppression, clients taking methotrexate should avoid large crowds of people to prevent becoming ill. Methotrexate should be taken with folic acid to decrease gastrointestinal and hepatic toxicity. Clients who are taking this medication should have a complete blood count test done regularly to monitor for decreased white blood cells and platelets, which can indicate bone marrow suppression. Methotrexate is teratogenic, therefore, pregnancy should be avoided while taking this medication. The nurse is caring for a client with osteoporosis who has been prescribed alendronate. When providing care, which intervention would be a priority? 1Notify the health care provider if the client reports jaw pain. 2Monitor the client's serum calcium levels. 3Encourage the client to increase their intake of vitamin D. 4Administer the alendronate 30 to 60 minutes before the client eats. - Solution 1 The office nurse is discussing how to prevent an acute gouty attack with a client who has gout. Which actions should the nurse recommend to the client? (Select all that apply.) Limit their intake of shellfish and red meats. Take the prescribed prednisone regularly. Limit their consumption of alcohol. Implement stress reduction techniques. - Solution limit shellfish/meat intake limit consumption of alcohol stress reduction techniques The nurse observes an unlicensed assistive person (UAP) providing care to a client who had a total hip arthroplasty 24 hours ago. Which action by the UAP would require the nurse to intervene immediately? 1Placing non-slip foot wear on the client prior to ambulation. 2Placing a raised toilet seat in the client's bathroom. 3Standing by the client's non-operative side during ambulation. 4Reminding the client not to cross their legs. - Solution 3 When assisting the client during ambulation following a total hip arthroplasty, the UAP should stand on the operative side (i.e., the side of the surgery) to help provide support to the client because that is the client's weaker side. The home health care nurse is caring for a client who has epilepsy. While the nurse is providing care, the client has a seizure. Which intervention would be most appropriate to prevent an injury to the client? 1Loosening clothing around the waist 2Asking the client to state where they are 3Lowering the client to the ground 4Placing a pillow under the client's head - Solution 3 notices the client is having trouble speaking and has stopped moving the right side of their face. What action the nurse should take first? 1Take the client's vital signs. 2Document the onset of symptoms in the medical record. 3Call 911. 4Ask the client if they have a headache. - Solution 3 An adult client who has been experiencing a seizure for approximately 15 minutes is brought to the emergency department by private vehicle. Which intervention should the nurse implement first? 1Obtain a STAT 12-lead electrocardiogram. 2Obtain a STAT electroencephalogram. 3Administer levetiracetam intravenously. 4Administer lorazepam intravenously. - Solution 4 The nurse is caring for a client who suddenly develops slurred speech and a facial droop. What diagnostic test would the nurse expect to be performed first? 1Echocardiogram 2Computerized tomography scan 3Arterial blood gas 4Chest X-ray - Solution 2 The off-duty nurse is helping to administer first aid following a mass casualty incident in the community. Emergency medical personnel at the scene have started to triage victims, using a common, color-tagging system. Which tag color usually indicates the highest priority for a victim to receive care? 1Green 2Red 3Yellow 4Black - Solution 2 The nurse in a long-term care facility is caring for an 89-year-old client with atrial fibrillation and a history of multiple falls. The client's medications include amiodarone, atorvastatin, baby aspirin and metoprolol. Which new finding should be of greatest concern to the nurse? 1Heart rate of 106 2Bibasilar crackles 3Right-sided facial droop 4SpO2 of 89% on room air - Solution 3 A postoperative client following a thyroidectomy suddenly develops difficulty breathing, stridor and an increase in swelling of the anterior neck area. What should the nurse do first? 1Activate the hospital's emergency or rapid response system. 2Check the client's blood pressure and heart rate. 3Ask the charge nurse to come see the client immediately. 4Place a heart monitor on the client and observe for dysrhythmias. - Solution 1 The nurse is reviewing discharge instructions with a client who has been prescribed ciprofloxacin following a minor burn injury. Which statement by the client requires additional teaching? 1"I can take ibuprofen for the pain related to this burn." 2"After healing, I should have no scarring from this burn." 3"I will not take ciprofloxacin prior to sun exposure." 4"I will protect my skin from the sun with sunscreen and clothing." - Solution 3 The nurse in the primary care office is speaking with a client who has contact dermatitis on both hands. The client wants to know how to manage the condition. Which interventions should the nurse recommend to the client? (Select all that apply.) Rubbing the area can alleviate symptoms. Applying a cold pack to the area can help. Avoid heat that can exacerbate symptoms. Corticosteroid cream is acceptable to use. Frequent handwashing is important. Using soap without fragrance is recommended. - Solution avoid heat corticosteroid acceptable to use use soap without fragrance Exposure to heat or cold may cause or exacerbate contact dermatitis. Rubbing the area may also exacerbate or spread symptoms. While washing hands after exposure to possible irritants is recommended, frequent handwashing is not. Soap with fragrance is an external irritant and may exacerbate symptoms, so fragrance-free soap is recommended. A barrier cream containing a corticosteroid is the most frequently prescribed topical ointment. The home health nurse is visiting a client who has peripheral artery disease. It is winter time and cold outside. While observing the client getting dressed, which clothing choice by the client should the nurse question? 1Two pairs of cotton socks 2A fleece hat with ear protection 3Wind-protecting pants and jacket 4A polyester fleece inner layer - Solution 1 A client is in the rehabilitation phase after suffering severe facial burns. Which behavior by the client best indicates that the client is coping effectively with the injury? 1The client appears cheerful when the spouse visits. 2The client asks for information about a support group for burn survivors. 3The client is looking forward to attending their high school reunion. 4The client plans to work from home after discharge from the facility. - Solution 3 The nurse is caring for a client who suffered second-degree burns over 50% of their body. The nurse understands that which medication is used for the prevention of stress ulcers for this client? 1Pantoprazole 40 mg IV daily 2Furosemide 40 mg IV daily 3Ibuprofen 400 mg PO every eight hours 4Bumetanide 2 mg PO every six hours - Solution 1 Curling's ulcers generally manifest themselves as gastric bleeding and are prevented by administering proton-pump inhibitors, such as pantoprazole. The home health nurse is visiting an older adult client who recently moved to this community from a much colder climate. The nurse provides the client with instructions on how to prevent a heat stroke. Which statement by the client indicates that additional teaching is needed? 1"I will not take my diuretic on days that I exercise." 2"I will increase my fluid intake if I develop cramps when exercising." 3"I will wear loose clothing and a hat when I walk my dog." 4"I will take my morning jog early in the morning when it is cool outside." - Solution 1